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•V v. 



NAVMED P-5088 




Vol. 45 



Friday, 26 March 1965 




No. 6 




SPECIAL ARTICLES 



Surgeon General's Message to All Hands 

DENTAL SECTION 



RADM Brown Assumed Duty as Chief of BuMed 

Rear Admiral Robert Owen Canada Deputy and Assis- 
tant Chief of BuMed 

A Trip to Southeast Asia 

Coming Soon 

MEDICAL ABSTRACTS 

Navy Tissue Bank — Past and Present 

Humeral Torsion 



Corticosteroids in Operative Dentistry 



FROM THE NOTE BOOK 

U.S. Navy's Submarine Medicine Program 

U.S. Naval Medical School Announces Four Cor- 
respondence Courses 

Erratum 



3 
4 

7 

7 
10 

13 

13 
14 



PERSONNEL AND PROFESSIONAL NOTES 
Navy Dental Officer Presentations 

Navy Dentists Participate in Centennial Midwinter 

Meeting 

Navy Civilian Researcher Honored 

Navy Dentist Receives Air Force Award 

List of Newly Standardized Items Available for Issue _ 
Reserve Dentist Named to Post at Pittsburgh School _ 
People to People International Relations 

OCCUPATIONAL MEDICINE 

Future of Health in Industry 

Diseases of White Collar Workers 



14 

17 

17 
18 
18 
19 
19 
19 



20 

25 



United States Navy 
MEDICAL NEWS LETTER 



Vol. 45 



Friday, 26 March J 965 



No. 6 



Rear Admiral Robert B. Brown MC USN 
Surgeon General 

Rear Admiral R. O. Canada MC USN 
Deputy Surgeon General 

Captain M. W. Arnold MC USN (Ret), Editor 
William A, Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine CDR J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine * CDR J. H. Schulte MC USN 



Policy 
The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of- the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to: Commanding Officer, U.S. Naval Medical School, 
National Naval Medical Center, Bethesda, Maryland 
20014, giving full name, rank, corps, and old and new 
addresses. 



FRONT COVER: Aerial view of U.S. Naval Hospital, Beaufort, South Carolina. This hospital, commissioned 
on 29 April 1949, is one of the Navy's most modern. The architecture and overall facilities of the hospital 
have been duplicated almost exactly in Peru for that country's Naval Medical Center. Three Peruvian Naval 
doctors spent some time at USNH, Beaufort several years ago and later served as advisers in construction of 
the new Peruvian hospital. 

Since the pre-Korean opening date there have been 61,031 admissions, including wounded returned from the 
Far East. The bed capacity for emergency admissions is 372, for normal operations 318, with 200 officially 
authorized beds. The population served averages about 23,956, represented by 6,383 military personnel sta- 
tioned at Parris Island Recruit Depot, 6,000 military recruits, 10,323 dependents, and 750 retired personnel. 
(Commanding Officer: Capt C. S. Hascall, Jr., MC USN) 

The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. 

U.S. NAVY MEDICAL NEWS LETTER 



SURGEON GENERAL'S MESSAGE 
TO ALL HANDS 



REAR ADMIRAL R. B. BROWN, UPON HIS SUCCESSION TO THE OFFICE 
OF SURGEON GENERAL, SENT THE FOLLOWING LETTER TO ALL 
FLEET AND FORCE MEDICAL OFFICERS AND TO ALL MEDICAL AC- 
TIVITIES UNDER THE MILITARY COMMAND OF THE CHIEF, BUREAU 
OF MEDICINE AND SURGERY. THIS LETTER IMPARTS A MESSAGE TO 
ALL PERSONNEL OF THE NAVY MEDICAL DEPARTMENT WHEREVER 
ASSIGNED. THEREFORE, IN ACCORDANCE WITH THE WISHES OF 
OUR NEW SURGEON GENERAL, THIS LETTER HAS BEEN INCLUDED 
IN THIS ISSUE OF THE U.S. NAVY MEDICAL NEWS LETTER: 



"It has been my privilege to participate in and, perhaps, in some measure, contribute to the accomplish- 
ments of the Navy Medical Department under the capable leadership of Admiral Kenney and other illustrious 
predecessors. I recognize the demands and responsibilities of the Office of Surgeon General. I accept this 
challenge with the obligation to earn and justify the confidence and support of those in positions of higher 
authority as well as the loyalty and cooperation of the dedicated and capable men and women who make up 
our Medical Department. 

I have always looked askance at the "new broom" type, the individual whose first acts in a job are to rad- 
ically change things. Change for change sake is not in my plans. All programs now in effect will be con- 
tinued but with expectation of modifying and improving them as indications arise and justifications are de- 
veloped. Our efforts to find better solutions to the problems of personnel, facilities, and funds, which are ever 
with us, will not be relaxed. As new policies or programs are being considered I plan to keep you fully 
apprised of them. 

This brings me to my first objective, that of improving communications between this Bureau and activities 
in the field. You are invited to submit problems which defy local solution and we, in turn, plan to visit you 
to obtain first hand information regarding your needs. The knowledge that your difficulties are fully under- 
stood and that corrective measures are being studied at this and higher levels should at least lessen frustration 
and encourage acceptability while solutions are being sought. This applies particularly to the frequent com- 
plaints and misunderstandings which arise over the equitable distribution of resources among our primary 
obligations to the operational forces, our often overwhelming commitments to patient care in all categories, 
and to training and research which are essential to competency and progress in our Medical Department. 

I am certain that I speak for everyone in the Medical Department, and for all of those whom it has been 
our privilege to serve, when I thank Admiral Kenney for his strong leadership of the past four years and for 
the warmth and understanding which have been reflected in his every action. I thank him personally, in addi- 
tion, for the heritage that is mine, our splendid Medical Department, and ask that each of you join me in a 
dedication to carry Navy medicine to ever greater heights." 



(ffils 



R. B. BROWN 

U.S. NAVY MEDICAL NEWS LETTER 



SPECIAL ARTICLES 



RADM BROWN ASSUMED DUTY AS CHIEF OF BUMED 



On 15 February, 1965 Rear Admiral Robert B. 
Brown MC USN, became Surgeon General and Chief 
of the Bureau of Medicine and Surgery. He had 
served since 1 August 1963 as Assistant Chief of 
BUMED for Personnel and Professional Operations 
and from 1 July 1964 as Deputy Surgeon General 
and Assistant Chief of the Bureau of Medicine and 
Surgery. 




Admiral Brown brings to his new assignment an 
illustrious record of achievements in behalf of the 
advancement of professional and administrative mat- 
ters within and outside the Medical Department of 



the Navy. Prior to his Bureau service some of his 
important duties were: 

Commanding Officer, National Naval Medical 
Center, Bethesda, Md. 

Commanding Officer, U.S. Naval Hospital, 
NNMC, Bethesda, Md. 

Clinical (Adjunct) Professor of Surgery, George- 
town University School of Medicine. 

Chief of Surgical Service and Chief of Professional 
Services, USS REPOSE (1950-1951)— for which 
Admiral Brown was awarded the Bronze Star Medal, 
The citation states in part: "For meritorious service 
as Chief of Professional Services and as Chief of 
Surgical Service in the Naval Hospital on board the 
USS REPOSE, in connection with operations against 
enemy aggressor forces in Korea from September 20, 
1950 to July 12, 1951. Throughout this period, 
CAPT Brown rendered outstanding services to his 
patients and directly supervised the surgical treat- 
ment of all casualties admitted to his section. Exer- 
cising exceptional professional skill and a thorough 
understanding of the scope and importance of his 
assignment, he was largely responsible for the excel- 
lent care given to the more than 8000 patients ad- 
mitted to the hospital and was greatly instrumental 
in saving the lives of many of the stricken men," 

Chief of Surgery, USS TRANQUILLITY, 1945 

Chief of Surgery, U.S. Naval Hospital, Annapolis, 
Md., 1943 

Duty aboard the USS SOLACE, 1943 

Having obtained the B.S. degree from Allegheny 
College, Meadville, Pennsylvania (1925-1929) and 
his Doctor of Medicine degree from the University of 
Pennsylvania (1929-1933), Doctor Brown received 
comprehensive graduate training at the University of 
Pennsylvania in General Surgery, and one year in 
Thyroid and Neurosurgery. During the period 1935- 
1 94 1 he also served variously as Assistant Instructor 
in Surgery at the Medical School there, Instructor in 
Surgery, and Assistant in Surgery at the University of 



U.S. NAVY MEDICAL NEWS LETTER 



Pennsylvania, Philadelphia General, Presbyterian and 
Doctors' Hospitals, In 1941 he received his Doctor 
of Science {in Surgery) degree from the University 
of Pennsylvania Graduate School of Medicine, Dur- 
ing the period 1933-1935 he interned at the Hospital 
of the University of Pennsylvania, 

In addition to the Bronze Star Medal, Rear Admiral 
Brown has the following service medals: Asiatic- 
Pacific Campaign Medal with one star; American 
Campaign Medal; World War II Victory Medal; 
National Defense Service Medal; Korean Service 
Medal; United Nations Service Medal; Expert Rifle- 
man Medal and the Expert Pistol Shot Medal. He 
also has the Korean Presidential Unit Citation. 

Dr. Brown is a Fellow of the American College of 
Surgeons and a Diplomate of the American Board of 



Surgery. He is a member of the Philadelphia County, 
the Pennsylvania State and American Medical Asso- 
ciations; the Society of University Surgeons; the 
American Surgical Association; the International 
Surgical Society; the Eastern Surgical Association; 
the Society of Vascular Surgery; the Southern Surgi- 
cal Association; the American Association for the 
Surgery of Trauma; and Associate Member, Clinico- 
Pathological Society, Washington, D.C. and Phila- 
delphia Academy of Surgery. In 1962 he received an 
honorary Doctor of Science degree from Allegheny 
College, Meadville, Pennsylvania. 

His official home address is 704 Chestnut Street, 
Meadville, Pennsylvania. He is married to the former 
Jane Richardson of Pitman, New Jersey, and has a 
daughter, Mrs. Joan Brown Cox of Indiana. 



REAR ADMIRAL CANADA, DEPUTY AND ASSISTANT CHIEF OF BUMED 



Robert Owen Canada, Jr., was born in Grottoes, 
Virginia, on 16 July 1913, son of Mrs. R. O. (Mary 
Crawford) Canada and the late Dr. Canada. He at- 
tended Augusta Military Academy, Fort Defiance, 
Virginia, and received the degrees of Bachelor of 
Science from the University of Virginia, Charlottes- 




ville, and Doctor of Medicine from that University's 
School of Medicine. He was commissioned Lieuten- 
ant (junior grade) in the Medical Corps of the U.S. 
Navy on 16 July 1938, after completing his intern- 
ship, and was subsequently advanced in rank to that 
of Rear Admiral, to date from 1 July 1964. 

Ordered first to the U.S. Naval Hospital, Ports- 
mouth, Virginia, he served as Ward Medical Officer 
there from August 1938 to April 1940, then reported 
to the USS SAUNAS (AO-19) for duty as Medical 
Officer. He was serving in that capacity when the 
SALINAS was torpedoed off Iceland by a German 
submarine on October 30, 1941, prior to the out- 
break of World War II. Detached in December 1941, 
he served until March 1944, as Officer in Charge of 
the Naval Unit at Fitzsimons General Hospital, Den- 
ver, Colorado. 

During the latter period of the war, he was again 
at sea serving as Senior Medical Officer of the USS 
PASADENA (CL-65) from her commissioning in 
June 1944, until November 1945. The PASADENA 
operated in the Pacific combat area from September 
1944 until August 15, 1945, participating in the 
capture and occupation of the Southern Palau Is- 
lands in September and October 1944; with the 
THIRD Fleet in the Leyte operation (including 
Luzon attacks) and the Luzon operation (including 
attacks on Luzon, Formosa, the China Coast and 
Nansei Shoto); with the FIFTH Fleet in the assault 
and occupation of Iwo Jima, made on Nansei Shoto 
and the Okinawa operation (including the assault 
and occupation of Okinawa Gunto); and THIRD 



U.S. NAVY MEDICAL NEWS LETTER 



Fleet operations against Japan. She was in the Tokyo 
Bay Area during the Japanese surrender and sub- 
sequent occupation of Japan. 

Returning to the United States, he reported in 
December 1945, to the Naval Hospital, Sampson, 
New York, where he served as Assistant Chief of 
Medicine until March 1947. He then had graduate 
instruction at Cornell Medical School, New York, 
New York, and in October of that year was de- 
tached for duty at the Navy Department, Washing- 
ton, D.C. There he served as Head of the Tuber- 
culosis Control Section, Bureau of Medicine and 
Surgery, until August 1950, when he was transferred 
to the Naval Hospital, National Naval Medical Cen- 
ter, Bethesda, Maryland, as Assistant Chief of Medi- 
cine and Head of the Chest Disease Section. In 
June 1952, he reported as Chief of Medicine at the 
Naval Hospital, Charleston, South Carolina. 

In June 1955 he was detached from Charleston 
for similar duty at the Naval Hospital, Oakland, 
California, and in February 1959 reported as Chief 
of Medicine at the Naval Hospital, National Naval 
Medical Center, Bethesda, Maryland. In June 1961 
he became Commanding Officer of the Naval Hospital 



at the Naval Air Station, Jacksonville, Florida, and in 
February 1962 returned to the Naval Hospital, Na- 
tional Naval Medical Center, Bethesda, Maryland. 
He commanded that Naval Hospital for two years 
and in February 1965 was designated Deputy and 
Assistant Chief of the Bureau of Medicine and Sur- 
gery, Navy Department, Washington, D.C. 

RADM Canada has the American Defense Serv- 
ice Medal with bronze "A"; the American Campaign 
Medal; Asiatic-Pacific Campaign Medal with one 
silver star and one bronze star (six operations); the 
World War II Victory Medal; Navy Occupation 
Service Medal, Asia Clasp; National Defense Serv- 
ice Medal; and the Philippine Liberation Ribbon with 
one star. 

Married to the former Julia Dent Salter of Annis- 
ton, Alabama, Dr. Canada has one son, Robert Owen 
Canada, III. His official residence is Grottoes, Vir- 
ginia. 

Dr. Canada is a Diplomate, American Board of 
Internal Medicine; a Fellow of the American College 
of Physicians and the American College of Chest 
Physicians; and a member of the American Thoracic 
Society and the American Medical Association. 



A TRIP TO SOUTHEAST ASIA 

By Sub Lt (U) David Morris, R.A.N. Republished by permissiion from the Royal 
Australian Medical Newsletter 2(2): 3-8, July 1964* 



The purpose of my visit to Singapore and Thai- 
land, during December 1963, and January 1964, was 
to look at viral research at the South East Asia 
Treaty Organisation Laboratory especially in con- 
junction with the locrl problem of Thai Haemorr- 
hagic Fever (THF), The original idea was to spend 
the whole vacation of eleven weeks there, but this 
was not possible. I spent four or five weeks in New 
Zealand, then flew with the Royal New Zealand Air 
Force to Singapore, where I was to spend three 
weeks. 

Singapore 

In Singapore, I was accommodated in the Wardroom 
of the Royal Naval base in delightful tropical sur- 
roundings and comfort. The base has six thousand 



* Our special thanks are extended to the Medical Director General, 
Surgeon Captain R. M. Coplans, Q.H.S., R.A.N, and to Surgeon 
Commander S. J. Lloyd, R.A.N. {Editor of R.A.N. Medical News- 
letter) for permission to present this illuminating article in the USN 
Medical News Ltr. — Editor. 



Britons and four thousand natives. The R.N. Sur- 
geons were most hospitable, inviting me to the Base 
Hospital for ward rounds, outpatient and radiology 
sessions, etc. They also arranged day visits, to three 
local hospitals. The R.N, Base Hospital is well 
known to R.A.N. Surgeons and I shall not elaborate, 
save to mention the obvious advantage to medical 
practice of having families and civilians to treat as 
well as Naval personnel. The large oriental popula- 
tion provides valuable medical experience. Special- 
ties include Surgery, Obstetrics, Gynaecology, Radi- 
ology and Medicine. I am indebted to Surgeon 
Captain Curjell, R.N., and staff for their hospitality 
and encouragement. 

The British Medical Hospital is a large establish- 
ment (approx 750 beds) where I attended a round 
with a Major in the Australian Army, a Queensland 
graduate, who is preparing for his M.R.A.C.P. It 
was interesting to see four cases of leptospirosis and 
three of malaria in one round. It will be this hospital 



U.S. NAVY MEDICAL NEWS LETTER 



that will bear the brunt of any casualties from 
Borneo. 

The Director of tuberculosis control services for 
Singapore Island, Dr. Wong, made me at home and 
explained the agressive attack being made on tuber- 
culosis in that area. Comparative figures show the 
incidence of tuberculosis to be falling towards that 
of Western countries. UN1CEF aid is invaluable in 
continuing this work. Localities are serially micro- 
xrayed and suspects are isolated, then investigated 
and if necessary treated at the modern chest hospital, 
Tan Tok Sing. 

Tan Tok Sing is a beautiful hospital of 750 beds. 
It is staffed by highly qualified practitioners, many 
of whom have, or are taking, higher qualifications 
in the United Kingdom. Chest surgery is undertaken, 
and at the time of my visit the services of a visiting 
chest surgeon were being sought for post-graduate 
instruction. The staff invited me to a Christmas 
party, where I was introduced to the delicacy Satay 
(highly flavoured pork or chicken on a straw), and 
later to luncheon with the RMO's. 

Spare time was spent by the pool at the Ward- 
room, in Johore Baru over the causeway on the 
mainland; rowing on Johore Straits; at Kranji War 
Memorial or the Cemetery for 27,000 allied soldiers 
at Changi near the famous War prison; or in the 
city with family friends. 

New Year's Eve was spent with Australians at 
Butterworth, on the mainland of Malaya over from 
Penang. On New Year's day I flew on to Bangkok 
with Malaysian Airways. 

Thailand 

The three weeks in Thailand were most profitable 
and enjoyable and made so by the frank hospitality 
of the Thais and Americans with whom I was to 
work and live. My host was Dr. Scott Halstead, 
U.S. Army Major directing the Virology Department 
of the SEATO Medical Research Laboratory in 
Bangkok. He had kindly arranged accommodation 
with Captain Keefe, a Veterinary researcher inter- 
ested in rabies. 

The Laboratory. This SEATO Lab, financed by 
the U.S. Army Medical Corps, is under the director- 
ship of a pathologist, Colonel Hansen, and has very 
liberal research aims, not all to direct military medi- 
cal advantage; within this liberal framework are 
several active research programmes. Many medical 
disciplines are represented e.g., Bacteriology, Pathol- 
ogy, Virology, Entomology, etc. 

The Senior researcher in each Department is a 
highly trained American with a staff of Thai assist- 



ants. The Virology Department is headed by Dr. 
Halstead and Thais (most of whom have U.S. post- 
graduate qualification in Science and/or Medicine) 
staff the three main sections, Isolation, Tissue Cul- 
ture, and Serology. They are assisted by locally 
trained technologists and Science graduates. In Virol- 
ogy, Dr. Halstead actively directs all phases of the 
research programme. I shall confine further remarks 
to the Virology Department. 

The building is very modern, air-conditioned in 
parts, and well equipped by the Rockefeller Founda- 
tion and SEATO. The specific viral problem in 
South East Asia is Thai Haemorrhagic Fever (THF) . 
This disease was first described in Manila in 1955 
by Professor W. McD. Hammon of Pittsburg. By 
the rainy season of 1956 it was found in epidemic 
proportions in Bangkok and has since reappeared 
every "wet" with increasing incidence. 

Thai Haemorrhagic Fever 

This fever is an acute viral illness of children with 
high mortality. It is caused by an arthropod-borne 
virus, related to the Dengue viruses. 

This may be shown ( 1 ) serologically by Haemag- 
glutination Tests, etc., (2) by isolation after repeated 
passage in mice then tissue culture. 

Its vector is the mosquito Aedes aegypti. These 
predominate in central Thailand in the rainy season 
of June to October. Man appears to be an inter- 
mediate host. 

Incidence. In 1959, 2418 cases were hospitalized 
with 240 deaths. In 1962, 6086 were hospitalized 
with 346 deaths. In previous years it was only seen 
in Bangkok and only in specific parts of that city. 
Now it is reported in the flat central area of Thai- 
land, and also Calcutta. A similar disease has been 
reported from Manila and Singapore. THF mainly 
affects children from 1 to 14 years, with maximum 
incidence around 3 or 4 years of age. Caucasian 
children are seldom affected. 

Pathology. Diffuse haemorrhages, probably due to 
capillary fragility and thrombocytopenia, are seen in 
all organs, mainly the skin, liver, spleen and heart. 

Clinical Features. It is a disease of acute onset 
with fever, malaise, hepatomegaly, splenomegaly, 
pain in the limbs, and petechiae particularly on the 
forearms and forehead; about the fourth day catas- 
trophic circulatory failure may occur, presumably 
from cardiac damage, with imminent death. It is 
not uncommon for a child to die on admission for 
"PUO", but these are often THF cases. 

Investigation. Serological tests should be positive 



U.S. NAVY MEDICAL NEWS LETTER 



but this takes time and tissue culture takes longer. 
Differential Diagnosis must include the purpuras, 
infectious mononucleosis and leukemia. Prognosis 
depends on treatment and the rapidity with which 
it is begun. 

Management. There is no specific treatment; im- 
mediate control of incipient circulatory failure is im- 
portant. Intravenous therapy is almost routine. 

Much work on isolation and epidemiology, and 
also of creating an awareness of the hazards of THF 
in South East Asia, has been done by Dr. Halstead, 
and his colleagues. 

The time I spent in the laboratory was divided 
between reading the literature and working in the 
various sections; noting, watching and assisting in 
routine procedures, e.g. preparing tissue culture 
media or inoculating mice. 

Professor Hammon, one of the world's foremost 
Virologists, visited Bangkok for three days whilst 
I was there. He is vitally interested in arbo viruses, 
especially in Asia. It was of value to hear him 
discourse over dinner on viral research throughout 
the world, e.g. in the Amazon (Belem) Europe and 
South East Asia. 

For two days I accompanied a Thai mosquito col- 
lecting group to a city and national park 160 kilom- 
eters from Bangkok, along the Thai-U.S. Friend- 
ship Highway. Larvae were collected in the streams 
and adults on bared legs at night. This was a pleas- 
ant opportunity to see rural Thailand. 

Colonel Pitts, a U.S. Army Officer and neighbour 
of my host, invited me to accompany a group of two 
Thai Colonels, two U.S. Colonels and one Thai 
Lieutenant by air for three days inspecting radio 
communications along the Laos border country. On 
the first day, we travelled by Caribou to Udorn, 
forty miles from the border, where I visited the Dis- 
trict Hospital (100 beds). The full wards were made 
to seem even more full with relatives living in. The 
medical officers here do a marvellous job. Next day, 
we came down by helicopter to Ubon where the 
R.A.A.F. has a summer base in a city of 50,000 
and district of 1,000,000. A hospital of 250 beds 
serves this area and is obviously overworked. There 
is an extremely high incidence of vesical calculi in 



this particular area. In this hospital alone the Super- 
intendent operates on 500 cases a year; about 2 per 
day. Baby boys often die from renal tract infections 
concomitant with or secondary to vesical calculi. Old 
men often have stones the size of emu eggs removed. 
This localised problem also attracts the attention of 
Dr. Halstead. The third day was spent flying to 
north-west of Thailand and then returning to Bang- 
kok. 

Back in the city I visited the Children's Hospital 
and here saw my first two cases of diphtheria (un- 
familiar to my generation) with the classical opaque 
membrane and inspiratory stridor; also a late THF 
case and a case of retinoblastoma. 

The new Tropical Medicine Hospital (400 beds) 
is very modern and extremely well appointed and it 
was here that I was shown two cases of classical 
elephantiasis involving the lower limbs. This too 
was valuable clinical experience for me. Filariae 
abound in the south of Thailand. This tropical dis- 
trict and its endemic diseases interest the Dean of 
the Medical Faculty of Chulalongkorn University, 
who has embarked on an active entomological re- 
search programme with special interest in the filariae. 
The Dean was especially interested in Australia, 
having visited Sydney, and reciprocated the greetings 
I conveyed to him from the University of Queens- 
land Medical School. 

Though much of the time was spent in the labora- 
tory, a good part was spent exploring the sights. 
These included the annual intervarsity soccer match, 
bargaining for goods; and seeing the exotic temples, 
the Temple of Dawn, the Royal Barges, the Floating 
Market, the ruined capital of Ayuddyah, etc; as well 
as watching Thai boxing. 

I returned to Singapore in late January, to con- 
nect with the RNZAF flight to Auckland and Bris- 
bane a few days later. 

My impression of Thailand is one of smiling hos- 
pitable people, bent on maintaining a Western style 
democracy in the face of a rapidly approaching 
Communist front, at the same time accepting and 
planning for their fast changing role in a far from 
quiescent South East Asia. 



FEDERAL HOSPITALS MEETING 
The Federal Hospitals Meeting in connection with 
the New England Hospital Assembly will be held at 
the Hotel Statler in Boston, Massachusetts on 31 
March 1965. A Military Section in conjunction with 
this meeting will be held on the above date and will 
be at least two hours in duration. 



By authority of the Chief of Naval Personnel, one 
retirement point may be credited to eligible Naval 
Reserve Medical Corps officers in attendance. Offi- 
cers are requested to register with the Commandant's 
Representative in order that attendance may be re- 
corded and reported. 



U.S. NAVY MEDICAL NEWS LETTER 



COMING SOON 

Through the combined efforts of Rear Admiral R. B. Brown MC USN, Surgeon General of the Navy, and 
Dr. Ben Eiseman, Professor and Chairman, University of Kentucky Medical Center, a new series of articles 
will appear in the U.S. Navy Medical News Letter. These concise articles will bring to the Medical Officer, 
wherever he may be stationed, the most recent developments in the medical world. Listed below is the tenta- 
tive list of the first series of these articles entitled, "What's New in the Treatment of the Injured." 

1 . Management of Septic Shock Complicating Trauma by Dr. Jerry Rosenberg 

2. Automatic Ventilators by Dr. Peter Bosomworth 

3. Vasodilators by Dr. Dean Morrow 

4. Hyperbaric Oxygenation by Dr. Dan Wingard 

5. Mannitol by Dr. Paul Weeks 

6. Saline in Burns and Shocks by Dr. Ben Rush 

7. Low Molecular Weight Dextran by Dr. Ben Eiseman 

8. THAM and Sodium Bicarbonate by Dr. Frank Spencer 



It is hoped that these articles will inspire timely contributions from other authors. 



— Editor 



THE NAVY TISSUE BANK— PAST AND PRESENT 

LCDR Michael F. Dolan MC USN* Medical Annals of the District of Columbia 
XXXIII(12): 600-602, December 1964. 



The Tissue Bank of the U.S. Naval Medical School 
at the National Naval Medical Center in Bethesda, 
Maryland has been in existence since the Korean 
conflict. It was the fruition of an idea conceived by 
Dr. George W. Hyatt (now Professor and Chairman 
of Orthopedic Surgery at Georgetown University) 
who organized the Bank primarily to procure, process 
and store tissues for orthopedic and reconstructive 
surgery on the casualties from that conflict. The 
passage of time has witnessed the evolution of the 
Bank from the original 1-room laboratory containing 
a small freeze-drying unit to its present suite of rooms 
and laboratories occupying V/z floors of the South 
Wing of Building No. 1 , National Naval Medical 
Center. 

The Tissue Bank Department of the U.S. Naval 
Medical School is divided into several divisions: the 
Bank itself with its operating-room facilities, storage 
facilities, and case registry; the tissue chemistry divi- 
sion which serves as a quality control laboratory as 
well as a laboratory conducting research relevant to 
the purpose of the Bank; an immunology division 
whose primary function is elaboration and elucida- 
tion of the homograft reaction; and the tissue culture 

* Director, Tissue Bank Department, U, S. Naval Medical School, 
NNMC, Bethesda, Maryland, Republished by permission of the 
Editor of Medical Annals of the District of Columbia. 



division concerned with the development and assay 
of methods of viable tissue storage. 

At present the tissues that we bank and some of 
their uses are split thickness skin, primarily used for 
covering burn patients; fascia, used quite extensively 
in Lowman procedures; dura, used for closure of 
meningeal defects; cortical bone, used as onlay grafts 
in fracture repair or spinal fusion; ground cancellous 
bone, used as a filler in curetted bone cysts; rib 
matchsticks, used as supplemental filling in back fu- 
sions; and cartilage, used in piastic and dental recon- 
structions. At one time arteries were banked rou- 
tinely, but because of innovations in the synthetic 
polymer field the Bank now receives very few re- 
quests for blood vessels. For this reason vessels are 
obtained and processed only at the specific request 
of a collaborator. We do not store eyes but occa- 
sionally procure eyes for the Washington Eye Bank 
when a request is made. 

The tissues are prepared by a process of freeze- 
drying and are capable of prolonged storage at room 
temperature without significant changes with regards 
to their clinical performance. The subjugation of 
tissues to this lyophilization procedure precludes via- 
bility so that when they are suitably reconstituted 
with physiologic saline they can only serve as bio- 



U.S, NAVY MEDICAL NEWS LETTER 



logically acceptable materials apparently incapable of 
initiating a homograft response 1 but capable of pro- 
viding protection or support. 2 

Principal interest in the past was directed toward 
the, production of a standardized clinically utilizable 
and useful product, and through the efforts of pre- 
vious directors this goal has been realized. 36 The 
present orientation is more toward basic and applied 
research with the ultimate goal of augmenting, and 
in some cases completely replacing currently avail- 
able banked tissues with more economical and read- 
ily available synthetic substitutes which may be 
equally or better able to accomplish particular jobs 
and developing techniques for viable tissue storage. 7 ' s 
It is thought that synthetic materials or anorganic 
heterograft material 8 will eventually replace a con- 
siderable number and possibly all of the different 
types of deposits of presently available lyophilized 
human material. Until this possibility is completely 
realized, however, we are continuing to explore new 
applications for the presently available product as 
well as evaluating the need for, and technical diffi- 
culties associated with the procurement and process- 
ing of new preparations. Indeed, this past year has 
witnessed the formulation of a collaborative study to 
test the effectiveness of processed iliac dowels in 
anterior spinal fusions. It has also seen the utilization 
of whole lyophilized fibulae in the replacement of 
"pencil thin" tibiae in an arrested case of osteogenesis 
imperfecta, the results of which are not presently 
available. Indeed, lyophilization and vacuum pack- 
ing have proved to be a most satisfactory method of 
processing canine tendons, 10 and a collaborative ef- 
fort is being made to evaluate the performance of 
human tendons similarly processed. The clinical 
utility of a segment of lyophilized distal femur with 
attached articular cartilage as a half-joint preparation 
is currently being explored by one of our collabo- 
rators 11 in a case in which the corresponding autoge- 
nous material had to be removed because of involve- 
ment by a giant-cell tumor. In this instance we are 
given some reason for optimism by the reports that 
the patient, 7 weeks post-surgery, exhibits 70° flexion 
in that joint and is capable of straight-leg lifting 
exercise. The graft itself demonstrates punctate areas 
of translucency consistent with revascularization. We 
are well aware of previous studies on this matter 12 
and those which have shown that there is a transient 
"take" period of several months' duration, after 
which time the graft finally sloughs. 13 We are also 
aware of serious reservations expressed by some 14 
on the matter of transplanting joints or half-joints to 
weight-bearing positions. Nevertheless, the value of 



lyophilized material for joint reconstruction with the 
concomitant preclusion of sufficient residual antigenic 
material to initiate a homograft response has never 
been ascertained as far as I know and may well per- 
form considerably better than those used, either fresh 
or stored at — 20°C. 12 ' 13 

There are several areas of basic as well as applied 
research currently being explored in our laboratories. 
Foremost among these are studies aimed at eluci- 
dating the biochemical and functional alterations at- 
tendant upon freezing cells and whole organs, with 
the idea of developing techniques for the prolonged 
storage of tissues in a state that will permit them to 
retain complete functional capacity over prolonged 
storage. Obviously, freezing is not the only means of 
preserving material; indeed, it may ultimately prove 
to be inferior to some other techniques, but we are 
exploring the potential applicability of this method 
for 2 reasons: (1) Our experience has been in the 
field of freezing and our laboratories are geared to 
perform pertinent studies in this area, and (2) there 
is evidence available from nature that organisms can 
tolerate freezing and even subsequent drying (e.g., 
bacteria, fungi, etc.), rendering them capable of pro- 
longed storage; several animals as well as isolated 
mammalian organs can withstand extreme degrees 
of hypothermia during which time metabolic activity 
is temporarily suspended or considerably depressed. 
Quite recently it has been shown 1 "' that unprotected** 
rat kidney can be frozen and thawed without loss of 
function to the extent that the cold-exposed kidney 
alone can maintain a unilaterally nephrectomized 
animal indefinitely with insignificantly elevated BUN 
values as the only residuum. I think that these 
studies establish at least one fact, viz., that the 
physiologic and biochemical insult mediated through 
the freeze-thaw cycle is not necessarily incompatible 
with the retention of viability and functional integrity 
in mammalian organs so exposed. However, when 
we attempt to repeat these and similar studies in dogs 
the best results that have been reported to date are 
restoration of normal function after taking the kidney 
down to a temperature of — 6°C. 10 ' 17 Attempts to 
lower this temperature have been unsuccessful in our 
hands to date although some recent evidence 18 indi- 
cates that this feat may well be possible. It appears 
at present that this problem may be resolvable only 
with recourse to the knowledge of the cryogenic 
engineers since the resolution of the problem of rapid 
heat exchange in a mass of tissue of such size as the 

**Not previously exposed to chemical agents known to afford some 
protection to cells against cold injury, e.g., dimethyl sulfoxide 
(DMSO), polyvinylpyrrolidone (PVP), glycerol, etc. 



8 



U.S. NAVY MEDICAL NEWS LETTER 



kidney may well be the elusive key to the matter of 
viable organ storage. 

The perfection of a method of viably storing tis- 
sues and organs, however, would be of only limited 
significance in the face of the homograft response. 
Consequently a good deal of our time and effort goes 
into attempts at more careful definition of the mecha- 
nisms of homograft reaction in order to lessen its 
significance to plastic and transplantation surgery. 
Exploration in this area is focused on the detailed 
histochemistry of the reaction and the incubation of 
grafts with selected metabolites in an effort to render 
the graft less antigenic to the host. 19 In more elabo- 
rate terms, we are seeking to render the graft's 
phenotype more compatible with that of the host. 
Our expectation is not that gene changes will neces- 
sarily occur from our treatment but that by suffi- 
ciently altering the phenotype a state of permanent 
tolerance may be achieved through adaptation. 

The other area of major interest is radiation pro- 
tection. The Tissue Culture Division has developed 
a system for short-term (up to 10 days) viable 
storage of human bone marrow 20 ; utilization of this 
material in clinical cases shows that the protective 
properties of autologous bone marrow have not been 
lost during storage. Prolonged frozen (1 year) stor- 
age of autologous canine bone marrow has also been 
shown in our laboratories to effect survival with 
almost the same efficiency as fresh preparations. 
More recently considerable attention is being given to 
the finding 21 that pooled homologous peripheral white 
blood cells from guinea pigs prepared by a modifica- 
tion of the fibrinogen flotation method of Skoog 22 
can significantly decrease the mortality statistics in 
lethally irradiated animals. These studies employed 
fresh as well as frozen and stored-cell populations. In 
the guinea-pig system no evidence of runting syn- 
drome has become evident after 6 months post- 
infusion. 2 " Studies of a similar nature are now being 
carried out on dogs in an attempt to successfully 
negotiate the phylogenetic pathway leading to man. 
Although these studies comprise our main pursuits, 
selected pilot studies are constantly opening new 
avenues and closing others so that major efforts will 
continue to be directed along the most promising 
roads. 



In an attempt to summarize the aspirations of the 
Navy Tissue Bank, I will relate the following story. 

When an official of the Massachusetts General 
Hospital was asked whether the operation to success- 
fully reanastomose an essentially completely severed 
limb was a unique accomplishment the reply was that 
the priority would have to go to the Arabian phy- 
sician-brothers Cosmas and Damian. 24 The reference, 
of course, was to the legend of the "Vision of the 
Black Leg" which has been perpetuated through the 
centuries and graphically portrayed in several hun- 
dred paintings going back to the fourteenth century. 
It tells of the removal of a cancerous leg from 
an otherwise healthy Caucasian by the physician- 
brothers and its replacement with a functional leg 
which had been removed from a Moor buried that 
same day. It is the realization of the biological im- 
plications of this legend and the capability of trans- 
planting bone marrow, kidney, skin, spinal cord, etc., 
which truly reflects the hopes of those of us in the 
field of tissue banking. Indeed, this legend and all 
that it implies might be cited as the reference for 
our motto "Ex Morte Vita" — "from death, life." 

REFERENCES 

1 Guttmann R. D., and Katz, M., in International Symposium, 
University of Padova, May 1963. Minerva Med, 1963, 54, 2489. 

2 Thomas, E. D., and Gresham, R. B.: Surg Forum, 1963, 14, 442. 
3. Dolan, M. F., and Heaton, J. A., in International Symposium, 

University of Padova: See ref 1. 

4 Gresham R B.: Freeze-dried cortical bone homograft-roentgeno- 
graphic and histological evaluation. Clin Orthop, 1964, 37 (No- 
vember), 

5 Sell K W., Hyatt, G. W., and Gresham, R. B., and Arte, C. P., 
editor: Research in Burns. Washington, D. C: Amer Inst Biol 
Sci, 1962, p 351. „ „ . . , 

6 Wilber, M. C., and Hyatt, G. W.: Bone cysts^results of surgical 
treatment in 200 cases, presented at the 27th Annual Meeting of 
the American Academy of Orthopaedic Surgeons in Chicago, 
January I960. 

7 Perry, V. P.: Fed Proc, 1963, 22, 102. 

«'. Gresham, R. B., Perry, V. P., and Wheeler, T. E.: JAMA, 1963, 

1 83 13 
9 Gresham, R. B., and Thomas, E. D.: Surg Forum, 1962, 13, 452. 
10. Potenza, A. D.: JAMA, 1964, 187, 187. 

11 Dehne, E.: Personal communication. 

12 Chase, S. W., and Herndon, C. H.: J Bone Joint Surg (Amer), 
1955, 37, 809. 

13. Herndon, C. H., and Chase, S. W.: Surg Gynec. Obstet, 1954, 98, 

273. 
14 Riordan D C. : Discussion of Entin, M. A., Alger, J. R„ and 

Baird, R. M.: J Bone Joint Surg Surg (Amer), 1962, 44, 1518. 
15. Bush, I. M.: Cryobiology, 1964, 1 (Supp. 1), 6. 

16 Deshpande, P. J., and Jacob, S. W.: Surg Forum, 1963, 14, 176. 

17 Monafo, W., and Dolan, M. F.: Unpublished observations. 

18" Henderson, I., Innes, B., Bickis, I., and Wilson, C: Cryobiology, 
1964, 1 (Supp 1), 15. 

19. Guttmann, R. D., Kraus, E. D., and Dolan, M. F. : Nature (Lon- 
don), 1964, 203, 196. w „ 

20. Perry, V. P., Pappas,, A. M., Wheeler, T. E., and Dolan, M. F.: 
Nutrient media storage of human bone marrow, in preparation. 

21 Perry, V P., Malinin, T. I., Kerby, C. C„ and Dolan, M. F.: 
Protection of lethally irradiated guinea pigs with homologous 
peripheral blood leukocytes, submitted for publication. 

22. Skooa, W. A., and Beck, W. S.: Blood, 1956, 11, 436. 

23 Malinin, T. I., Perry, V. P., Kerby, C. C, and Dolan, M. F.: 
Peripheral leukocyte infusion into lethally irradiated guinea pigs, 
submitted for publication. 

24. Shaw, R. S.: Spectrum, Jan-Feb 1963, p. 8. 



EYE DONORS 
In 1963, 1,112 eyes were donated to the Eye- 
Bank for Sight Restoration, Inc., an organization 
founded in 1944 to handle sight-saving elements 
from donor to patient and to conduct a research 



program. One-half of the 1963 eye donations were 
found suitable for corneal grafts; the remainder were 
used for detached retinal surgery and as research 
material. — Public Health Reports 80(1): 10, Jan- 
uary 1965. 



U.S. NAVY MEDICAL NEWS LETTER 



HUMERAL TORSION 

CAPT John H. Cheffey MC USN*. From the Proceedings of the Monthly Staff 
Conferences, U. S. Naval Hospital, NNMC, Bethesda, Md. 1961-1962. 



Recurrent dislocation of the shoulder is a relatively 
common affliction. It occurs in young adults, pre- 
dominantly males, and usually begins with an original 
dislocation which is produced with moderately severe 
trauma; despite adequate immobilization following 
the initial dislocation, recurrences ensue. The classi- 
cal history relates that recurring dislocation is pro- 
duced by minor trauma, or simply by a certain 
motion which the patient learns to avoid. Bilateral re- 
current dislocation of the shoulder is not uncommon 
and gives further support to prevailing evidence that 
multiple factors, including anatomical variations, pre- 
dispose individuals to this condition. 

Many theories have been offered to explain its 
occurrence. More than 70 surgical procedures have 
been described for its correction with little in com- 
mon except that the most successful are those which 
limit external rotation of the shoulder and thereby 
keep the humeral head in the glenoid fossa. 

Doctors Debevoise 1 , Cheffey-, and Hyatt 3 , several 
years ago, proposed that one factor in the biome- 
chanics of the habitual dislocator is abnormal gleno- 
humeral relationship due to an increased amount of 
humeral torsion, 

A report on preliminary investigation was pre- 
sented here to the Orthopaedic Forum Club in 1960, 
but the material has not as yet been published. 

Torsion of the humerus is an anatomical charac- 
teristic which has received considerable attention 
from anthropologists and anatomists, but thus far 
the literature contains no information as to its clini- 
cal significance. 

From the anthropologic viewpoint, many interest- 
ing aspects of humeral torsion in man and other ani- 
mals can be found in the numerous studies pub- 
lished over the past century. Prior to 1945 many 
controversial and conflicting opinions existed regard- 



♦ Chief of Orthopedic Service, USNH, NNMC, Bethesda Md at 
FrTt presentation; now assigned to SECNAV for duty — 



10 



ing the evolutionary development and the method 
of measurement of humeral torsion. In 1945 Evans 
and Krahl published their comprehensive studies on 
the phylogenetic development of humeral torsion; 
Krahl's later report in 1947 added further clarity to 
the subject when he reported his findings regarding 
humeral torsion in man. By measuring a large num- 
ber of specimens they found that the average humeral 
torsion in the adult is 74 degrees, and that the 
amount of torsion on the right is generally greater 
than the left by several degrees. Krahl found that an 
average primary humeral torsion of evolutionary 
origin amounting to 42 degrees exists in the humas 
fetus at 20 weeks of gestation. He concluded from 
further studies that the additional humeral torsion 
which occurs beyond this basic 42 degrees is sec- 
ondary and reflects the effect of muscular pull on 
the proximal humerus during growth and develop- 
ment. 

The clinical significance of the variation in hu- 
meral torsion has not been established at the present 
time, but there are certain aspects worthy of con- 
sideration in this regard. We know from the work 
of Doctors Dunlap and Shands on femoral torsion 
published in the Journal of Bone and Joint Surgery 
in 1953 and 1958 that torsion of the femur changes 
with growth from the time of birth to adolescence 
and adulthood, and there are certain clincal entities 
associated with femoral torsion, such as congenital 
dislocation of the hip. No analogous situations occur 
with the humerus as far as is known at present. 
However, the concept presented by Doctor Debe- 
voise, that an increase in developmental 'umeral 
torsion might be a factor in the occurrence of recur- 
rent dislocation of the shoulder, is the basis for the 
study described herein. 

In their preliminary work on this project Doctors 
Debevoise, Hyatt, and Cheffey developed a technique 
for roentgenograph ic determination of torsion of the 
humerus in the living subject. In a series of normal 

U.S. NAVY MEDICAL NEWS LETTER 



human subjects they measured the torsion by this 
technique; the results were compared with the 
amount of torsion found in a series of individuals 
who had had recurrent dislocations of the shoulder 
joint. Their results, in a relatively small series of 
cases, tended to support the hypothesis that an in- 
creased amount of torsion predisposes an individual 
to recurrent dislocation of the shoulder. Prior to un- 
dertaking the measurements of a series large enough 
for statistical analysis, it was necessary to demon- 
strate that the method of measurement is valid. 

Torsion of the humerus is measured differently 
than torsion of the femur. The basic points of refer- 
ence should be well understood before clinical appli- 
cations are considered. 

Torsion is the amount of "twisting" of one end of 
the humerus in relation to the other. The axis of 
each end is determined by the position of the arti- 
cular surfaces and bony prominences. The axis of 
the humeral head is at one end and the epicondylar 
axis is at the other. The epicondylar axis goes 
through the medial and lateral epicondyles and ro- 
tates around the axis of the shaft of the humerus as 
torsion occurs. The epicondylar axis and the shaft 
define the "epicondylar plane." The angle between 
the "epicondylar plane" and the plane formed by 
the shaft and the axis of the humeral head determines 
the amount of torsion. 

The increased torsion which occurs in man in com- 
parison to lower animals has developed as an adap- 
tation to assuming the upright position. In the lower 
animals in which less torsion is present the scapulae 
are located on the lateral aspect of the thorax, so 
that the head of the humerus faces posteriorly with 
the coronoid fossa facing anteriorly. 

In humans the scapulae come to lie more pos- 
teriorly with the glenoid facing more laterally. With 
this shift, the articular surface of the humeral head 
comes to face more medially. In the anatomical 
position in man the humeral head faces postero- 
medially while the coronoid fossa is facing anteriorly. 
In order to clarify what angle is measured, com- 
parison of various hypothetical angles of torsion is 
made. If one considers the humeral head stationary 
and centered in the glenoid fossa, the positions of 
the elbow and forearm can be described to demon- 
strate the corresponding amounts of torsion in ex- 
amples of different angles. At zero degrees of tor- 
sion, which does not occur in humans, with the 
elbow flexed to 90 degrees, the forearm would be in 
a position of marked external rotation with humeral 
head centered in the glenoid fossa. With 45 degrees 
of humeral torsion, the forearm would be more in- 



ternally rotated from that of zero degrees to a posi- 
tion of approximately neutral. While at 90 degrees 
of humeral torsion, with the humeral head centered 
in the glenoid fossa, the forearm is approximately 
45 degrees internally rotated. This amount of tor- 
sion seldom occurs in humans, but it can be seen 
that if such an individual externally rotates his fore- 
arm in the extreme, the humeral head is brought 
out of the glenoid fossa to a precarious extent. 

Roentgenographic determination of torsion of the 
humerus as devised by Doctor Debevoise was fash- 
ioned after that of Dunlap and Shands for Fermoral 
Torsion, as they reported in the Journal of Bone 
and Joint Surgery. A jig was designed for placing the 
arm (humerus) in a living subject in a position of 
slight abduction in order to take a lateral view of 
the humeral head; from this x-ray an angle of "ap- 
parent" torsion was measured. An AP x-ray of the 
humeral head is also taken to measure the "appar- 
ent" neck-shaft angle. The "apparent" angle of tor- 
sion, and the "apparent" neck-shaft angles are used 
in a three-dimensional trigonometric formula to cal- 
culate the "true" angle of torsion. 

This paper is a report on a study made to demon- 
strate the accuracy of this x-ray technique of measur- 
ing humeral torsion in human beings. 

Twenty-five human humerus specimens were ob- 
tained from the Smithsonian Institution for this proj- 
ect. Two x-ray views of each of the 25 specimens 
were made and the amount of torsion for each was 
calculated. An instrument called a torsiometer, ori- 
ginally designed by Krahl, was used to measure 
visually the actual torsion of each specimen directly. 
The measurements from the x-rays were then 
used with the formula to calculate the 'true" torsion 
of each specimen. The calculated torsion of each 
was then compared with the actual torsion as meas- 
ured directly with the torsiometer. The difference 
between the two was considered as a plus or minus 
so-many degrees of error. 

Figure 1 shows the calculated torsion of the spe- 
cimens superimposed on the actual torsion as meas- 
ured directly with the torsiometer. 

The solid line and dots show the variation of 
torsion in the 25 specimens as measured directly. 
The range was from 48 degrees to 85 degrees and 
the average was 65 degrees. This is nine degrees 
less than Krahl's average of 74 degrees; however, his 
value was based on a considerably larger number of 
specimens. 

The torsion of each specimen calculated from the 
x-ray technique is shown by the dotted line. The 



U.S. NAVY MEDICAL NEWS LETTER 



11 




INDIVIDUAL HUMERUS SPECIMENS 
FIGURE I. 



variation of each individual specimen is shown by the 
distance between each dot and triangle on the same 
vertical axis. 

These are the results obtained. All of the 25 
specimens were measured within an accuracy of 9 
degrees. 

Eight out of the 25 specimens were within 1 
degree of error. Fifteen out of the 25 were within 
2 degrees. Twenty-one out of 25 were within 5 
degrees. 

An attempt was made to find an explanation for 
the discrepancies in measurement by inspection of the 
specimens which had shown the greatest error. It 
was found that the younger bones were more accu- 
rately measured, while the older bones had greater 
irregularities of the articular margins of the humeral 
head, and this led to inaccurate estimation of the 
extent of the articular surface from the x-rays. 

There are many aspects of such a project as this 
which require estimation rather than precise meas- 
urement. For this reason, accuracy greater than plus 
or minus 5 degrees cannot be expected. 



Krahl states that the torsiometer can measure 
within an accuracy of plus or minus one degree. 
This provides a basis for degree of accuracy of the 
direct measurement of the specimens in this series. 
However, an accuracy within one degree is certainly 
attained only after long experience. 

In conclusion, the amount of humeral torsion in 
25 human specimens was determined by a special 
x-ray technique. The actual torsion was then meas- 
ured directly and compared with the results of the 
x-ray technique. The margin of error was found to 
be relatively small. 

On the basis of this study it appears that the 
technique for roentgenographic measurement of hu- 
meral torsion as devised by Doctors Debevoise, 
Hyatt, and Cheffey, has an accuracy well within 
practical limits. 



REFERENCES 

resident (Othopedic Surgery, 



U.S, Naval Hospital, 



1 . Previously 
Bethesda) 

2. Chief of Orthopedic Surgery, U.S. Nava] Hospital, Bethesda. 

3. Previously Director, Tissue Bank, Naval Medical School, Bethesda. 
Now Chief of Orthopedic Surgery, School of Medicine, George- 
town University, Washington, D. C. 



12 



U.S. NAVY MEDICAL NEWS LETTER 



FROM THE NOTE BOOK 



THE U.S. NAVY'S SUBMARINE 
MEDICINE PROGRAM 

The School of Submarine Medicine convenes 
twice a year at the U.S. Naval Submarine Medical 
Center, Submarine Base, New London, Connecticut. 
Each class is approximately six months in duration. 
The curriculum includes: Basic Submarine Training, 
underwater physiology, hyperbaric physiology, psy- 
chiatry, dentistry, toxicology, environmental psysiol- 
ogy and radiobiology. Successful completion of the 
course is creditable toward certification by the Amer- 
ican Board of Internal Medicine and the American 
Board of Preventive Medicine. Upon completion of 
this course of instruction, students are assigned to a 
tour of operational duty in the submarine force. 
During this tour, the student prepares a thesis and 
passes a comprehensive examination on submarine 
and diving medicine and is then designated a "Quali- 
fied Submarine Medical Officer." 

By serving as a ship's medical officer on board a 
polaris submarine or as a squadron medical officer 
in a submarine squadron, the submarine medical 
officer not only takes care of the usual health prob- 
lems of the submarine personnel, but he also devel- 
ops an awareness of the potential health and safety 
hazards which exist aboard submarines. Having 
determined that a health problem may exist, he com- 
municates his findings to the Submarine Medical 
Center or is transferred to the Center so that he can 
thoroughly investigate the problem and develop ap- 
propriate protective measures for the operating sub- 
marine force. As a consequence of this procedure, 
the Submarine Medical Center has been instrumen- 
tal in the development of most of the health protec- 
tion programs in existence on submarines including 
atmospheric and environmental controls, noise re- 
duction and ear protection, adequate light and vision 
conservation, and shielding design and protection 
from ionizing radiation, to name a few. 

After completing a tour of duty with an opera- 
tional unit, the medical officer may apply for post- 
graduate training in various fields. He may prepare 
for certification in preventive medicine and obtain a 
graduate degree by attei !ing one of the Schools of 
Public Health or Industrial Medicine. He may pre- 



pare himself for a career in research and obtain a 
graduate degree in diving physiology or radiobiology 
by attending one of the appropriate civilian univer- 
sities. This course of action would be followed by 
duty at naval research laboratories and with the oper- 
ational forces. If he prefers a clinical specialty, he 
may obtain a residency in any of the recognized 
clinical specialties. 

Applications are now being accepted in the Bu- 
reau of Medicine and Surgery for courses convening 
in August 1965 and February 1966. 

Further information on Submarine Medicine may 
be obtained by writing to: CDR J. H. SCHULTE 
MC USN, Director, Submarine and Radiation Medi- 
cine Division, Bureau of Medicine and Surgery, 
Navy Department, Washington, D. C. 20390. 

U. S. NAVAL MEDICAL SCHOOL ANNOUNCES 
FOUR CORRESPONDENCE COURSES 

The Medical Department correspondence courses 
"Tropical Medicine in The Field," NavPers 10995- 
A; "Bacteriology And Mycology," NavPers 10504; 
"Biochemistry," NavPers 10503; and "Serology," 
NavPers 10502 are now ready for distribution to 
eligible regular and reserve officer and enlisted per- 
sonnel of the Armed Forces. Applications for these 
courses should be submitted on form NavPers 992, 
with appropriate change in the "To" line, and for- 
warded via official channels to the Commanding 
Officer, U.S. Naval Medical School, National Naval 
Medical Center, Bethesda, Maryland 20014. A de- 
scription of these courses is delineated below: 

Tropical Medicine In The Field, NavPers 10995- 
A. 12 Assignments — 36 Points. Provides a concise 
guide in tropical medicine for the physician who may 
be called upon to practice in the tropics, and for 
the physician in temperate zones who may encounter 
tropical diseases of servicemen and others returning 
to the United States after duty in the tropics. Text: 
A Manual of Tropical Medicine, by Hunter, Frye, 
and Swartzwelder, 3d Edition, 1961. 

Bacteriology and Mycology, NavPers 10504. 3 
Assignments — 6 Points. This is one of six courses 



U.S. NAVY MEDICAL NEWS LETTER 



13 



in the Clinical Laboratory Procedures series, and 
deals with the collection of bacteriological speci- 
mens; identification, classification, and characteristics 
of bacteria and funy. Water and milk bacteriology, 
laboratory organization, serological testing and anti- 
biotic sensitivity testing are also thoroughly covered. 
Text: Bacteriology and Mycology, U.S. Naval Medi- 
cal School, NavPers 10865-BIV. 

Biochemistry, NavPers 10503. 3 Assignments — 6 
Points. This is one of six courses in the Clinical 
Laboratory Procedures series and presents laboratory 
organization, colorimetric and photometric tech- 
niques, gasometric analysis, collection and preserva- 
tion of specimens, and over 75 biochemical proce- 
dures are covered. In addition, there are 20 
illustrations of laboratory instruments and an exten- 
sive bibliography. Text: Biochemistry, U.S. Naval 
Medical School, NavPers 10865-AIII. 

Serology, NavPers 10502. 3 Assignments — 5 
Points. This is one of the six courses in the Clinical 



Laboratory Procedures series, and deals with tech- 
nique of venipuncture, shipment of specimens, han- 
dling of glassware, and general technique as well as 
specific instructions for VDRL, Kolmer Comple- 
ment, Mazzini Microflocculation, Treponema Palli- 
dum immobilization, and other tests. Text: Serology, 
U.S. Naval Medical School. 

Individuals who have previously completed the 
course in Clinical Laboratory Procedures, NavPers 
10994, and Tropical Medicine in the Field, NavPers 
10995 will receive additional credit for completing 
these courses. — Submitted by CAPT John H. Stover 
Jr. MC USN, Commanding Officer, U.S. Naval 
Medical School, NNMC, Bethesda, Md. 

ERRATUM 

Page 21, line 4 under "DISCUSSION" Volume 
45, Number 5 of the U.S. Navy Medical News Letter 
should read: A well-outlined program is now avail- 
able. . . . — Editor 



DENTAL SECTION 

CORTICOSTEROIDS IN OPERATIVE DENTISTRY 
LCDR William R . Cotton DC USN 



The advent of the clinical use of corticosteroids 13 
years ago introduced to dentistry a new therapeutic 
approach for the treatment of dental disease. The 
popularity of these drugs is manifested by the in- 
creasing number of reports in the literature on their 
use. This report contains a review and evaluation of 
the present knowledge concerning the use of the 
corticosteroids in operative dentistry. 

The adrenal corticosteroids are divided into two 
classes: the mineralcorticoids (sodium-retaining hor- 
mones) and the glucocorticoids. The latter have been 
used in dentistry for temporo-mandibular joint ar- 
thritis, periodontal lesions, endodontic treatment, and 



diseases of the oral mucosa. The glucocorticoids 
diminish the body's natural defenses against stress, 
impair vascularization, and interfere with the forma- 
tion of fibroblasts, granulation tissue and ground 
substance. Their main use in dentistry has been the 
control of inflammation. 1 The corticosteroids de- 
crease the permeability of cell wall of the mast cell 
inhibiting the release of histamine and heparin; there- 
by, decreasing the inflammatory response. 

There has been much recent interest in the appli- 
cation of corticosteroids in operative dentistry to 
relieve postoperative dentin and pulp sensitivity and 
to treat exposed pulps. The earliest works 2i 3 reported 



14 



U.S. NAVY MEDICAL NEWS LETTER 



considerable clinical success in the treatment of ex- 
posed pulps. However, the number of treated teeth 
was small and the follow-up period was short. 

Kiryati 4 studied the effect of hydrocortisone with 
antibiotics on experimentally lacerated rat pulps. A 
combination of hydrocortisone and antibiotics in- 
creased the survival of pulp tissues after injury and 
infection, but the part played by hydrocortisone was 
uncertain. Treatment of pulps with hydrocortisone 
alone showed 22% complete healing. Combined 
treatment with hydrocortisone, oxytetracycline and 
chloramphenicol showed 63% complete healing. 
Treatment with oxytetracycline and chloramphenicol 
without hydrocortisone showed 35% of the teeth to 
have complete healing; and treatment with hydro- 
cortisone, Neomycin and bacitracin gave 18% with 
complete healing, Kozlov and Massler 5 also found 
after 14 days, evidence of reparative dentin bridging 
in amputated pulps of rat molars which were treated 
with cortisone or hydrocortisone alone. 

Much of the interest in dentistry has been due to 
the work of Fry, Watkins and Phatak" and Mostel- 
ler 7 - 8 who employed a mixture of Meticortelone 
(Shering brand of prednisolone), camphorated para- 
chlorophenol and metacresylacetate to reduce post 
operative dentin sensitivity. It should be pointed out 
that metacresylacetate (Cresatin) is in itself a potent 
antiseptic and anodyne. 

Fry et al. 6 applied the mixture to exposed dentin 
and sealed the cavity with a zinc oxide-eugenol resto- 
ration or placed it directly over an exposed pulp, 
occasionally modified by placing an autoclaved as- 
bestos disk or cigarette paper over the medication, 
after which zinc oxide and eugenol was placed. They 
were highly selective in their choice of teeth to be 
treated and did not use controls. All but one of the 
43 teeth remained pain -free based on a 4-month 
observation period. 

Mosteller, 7 in an uncontrolled clinical study, ap- 
plied the prednisolone mixture under 726 gold resto- 
rations; one week postoperatively, all teeth except 3 
were free of thermal sensitivity to 46° F water. 
Mosteller 8 repeated his original study in a controlled 
clinical experiment in which the prednisolone mixture 
was applied to only one side of the patient's mouth. 
One week later the treated teeth were insensitive to 
46° F water; whereas, over 50% of the untreated 
teeth were sensitive. The mixture was applied to 
cavities in 3 sound human teeth while 3 similar 
cavities remained untreated. 

The 3 untreated teeth showed marked inflamma- 
tory changes within their pulps. The 3 prednisolone 



treated teeth demonstrated pulpal inflammation to a 
lesser degree. The number of teeth and the differ- 
ence in inflammation were both too small to draw a 
significant histological conclusion. 

Vigg 9 employed a mixture of 1% hydrocortisone 
and 3% oxytetracycline in an ointment base over 
exposed vital pulps in an uncontrolled clinical study. 
After 20 months 18 of 20 teeth were symptomless. 
In another group, after 6 months all 27 teeth were 
symptomless. In all instances pain, if present, dis- 
appeared immediately or within a few hours following 
use of corticosteroids. 

Lederle Laboratories have been marketing Leder- 
mix A (paste) and Ledermix B (cement) in Britain 
and Central Europe since March 1963. The former 
is essentially triamcinolone in a water soluble base. 
The latter is basically a zinc oxide-eugenol combina- 
tion with triamcinolone. Ehrmann 10 has reported his 
clinical impressions on the use of Ledermix on 200 
teeth over an 11 month observation period. Thermal 
sensitivity was considerably reduced in deep cavities 
and crown preparation lined with Ledermix. In 
hyperemia and early pulpitis the pain ceased in the 
majority of cases. In pulp exposure there was an 
absence of postoperative pain following treatment 
with Ledermix. 

Previous to the work of Fiore-Donno and 
Baum, 11 ' " systematic histologic controls of pulp re- 
sponse to corticosteroids have been made primarily 
on rat molars.*' 5 In their study of the histological 
response of human pulps with painful pulpitis capped 
with a corticosteroid antibiotic, they report that the 
corticosteroids, not only inhibit inflammatory sys- 
tems, but also inhibit the chief functions of the pulp 
to form reparative dentin by causing a connective 
tissue metaplasia. Pulps capped with a mixture of 
a corticosteroid, calcium hydroxide and antibiotic 
remained symptom-free and had a normal histologic 
picture 2 or 3 months postoperatively. It appears 
that calcium hydroxide assisted in overcoming the 
inhibition of reparative dentin formation, but in their 
later work they found this not to be true. 

What appears to be the best controlled study to 
date was recently reported by Dachi, Ross and 
Stigers. 13 Pairs of class V amalgam cavities were 
prepared as close to the human pulp as possible and 
coated as a blind with either prednisolone or placebo. 
The prednisolone was used alone rather than in com- 
bination with other drugs. The teeth were tested 
postoperatively for thermal sensitivity to cold and 
heat, and for vitality. After 7 days the teeth were 
extracted and evaluated histologically. Prednisolone 



U.S. NAVY MEDICAL NEWS LETTER 



15 



was slightly more effective than placebo in relieving 
sensitivity. In comparing the experimental and con- 
trol groups of teeth no difference in histologic reac- 
tion could be discerned. The inflammatory changes 
in both the prednisolone and placebo-treated teeth 
were severe under the stringent conditions of this 
experiment which included only teeth with 500 
microns or less of remaining dentin. The 7 day ob- 
servation period was too short to determine any 
inhibition of reparative dentin formation by pred- 
nisolone as reported by Fiore-Donno and Baume. 11 ' 12 

Unfortunately most of the recent interest by clini- 
cians has been based on reports of clinical observa- 
tions 6 > T - 8 - "- 10 of the effectiveness of corticosteroids 
in operative dentistry. Judging the efficacy of a drug 
or restorative material on clinical observations alone 
are unwarranted. The restorative material or medica- 
ment, especially corticosteroids, may obscure the 
clinical subjective symptoms which may be indicative 
of the true histopathological picture. 

From human histological evaluations, observation 
periods ranging from 15 to 300 days, there is evi- 
dence that the corticosteroids do inhibit dentino- 
genesis when employed in pulp capping, 11 * 12 which 
possibly may be overcome by the addition of calcium 
hydroxide 4 even though there is some evidence that 
calcium hydroxide and corticosteroids are antagonis- 
tic. 11 ' 12 Following corticosteroid capping in rats, 
reparative dentin formation has been reported as 
early as 7 to 14 days. 4 ' 5 Other investigators" have 
not reported reparative dentin formation in humans 
after a 7 day observation period. It is apparent that 
the corticosteroid effect on reparative dentin forma- 
tion is unsettled. 

Most investigators agree that there is an antiphlo- 
gistic effect on the pulp when the corticosteroids are 
used for pulp capping. This is accompanied by de- 
sirable pain relief but the interruption of the natural 
defense mechanism by steroids is not necessarily 
desirable. 1 This undesirable effect may be partially 
overcome by the addition of antibiotics to the corti- 
costeroids which seems to increase the survival of 
pulps after injury and infection.* 

The efficacy of corticosteroids, combined with 
other drugs, to eliminate dentin hypersensitivity is 
well documented. 6 ' 7 ' s - 10 The credibility of these 
earlier clinical studies has been confirmed by Dachi 
et al. 13 who employed prednisolone alone and found 
the prednisolone to be slightly more effective than a 
placebo. 

The safety of the topical use of corticosteroids has 
been questioned. 1 * As Ehrmann 10 points out, one 



application in a cavity, 0.01-0.05 mg. would be 
used, and this is one thousandth of the daily thera- 
peutic dose. It is doubtful whether much of this 
would be absorbed systemically, even though radio- 
actively labeled topically applied corticosteroids have 
been shown to diseminate throughout the pulp. 15 

In summary, the use of adrenal glucocorticoids 
(cortisone, hydrocortisone, prednisolone, triamcino- 
lone) for pulp capping is of questionable value. It 
appears that the proper selection of teeth for cap- 
ping is as important as the drug applied. Teeth with 
pulpitis did not heal adequately when treated with 
corticosteroids, 11 ' 12 while teeth with essentially 
healthy bleeding pulps healed with reparative dentin 
formation, *■ 5 ' * even though in both cases there was 
relief of pain. This relief of pain is not indicative 
of the pulp histology; therefore it is a blessing in 
disguise. 

Use of corticosteroids should be viewed as an 
adjunct and not as a substitute for the conventional 
measures of pulp protection, such as calcium hydrox- 
ide, zinc oxide-eugenol, cavity varnish and cement 
bases. Since naval personnel are, and will be, sub- 
jected to unique environments where the availability 
of dental care is not obtainable, use of corticosteroids 
for pulp capping procedures should be limited to 
selected cases involving vital, asymptomatic pulps. 

REFERENCES 

1. Hendershot, L. C. The Use of Adrenocorticosteroid Hormones in 
Dentistry, D. Clin. North American, July 1963, pp. 503-512. 

2. Rapopoit, L. and Abramson, I, I. Application of Steroid Hor- 
mones in Pulp-Capping and Pulpotomy Procedures. A Preliminary 
Report, Oral Surg., Oral Med. and Oral Path., 11: 545-548, 
May 1958. 

3. Fetnchneider, I. L, L'hydrocortisone, precieux adjuvent au trait- 
ment d'endodontie, J. Can. D. Ass., 27: 203-209, Jan 1961. 

4. Kiryati, A. A. The Effect of Hydrocortisone Plus Polyantibiotics 
Upon the Damaged and Infected Dental Pulp of Rat Molars, 
J. D. Res., 37: 886-901, Sept-Oct 1958. 

5. Kozlov, M. and Massler, M. Histologic Effect of Various Drugs 
on Amputated Pulps of Rat Molars, Oral Surg., Oral Med. and 
Oral Path., 13: 455-469, April 1960. 

6. Fry, A. E., Watkins, R. F. and Phatak, N. M. Topical Use of 
Corticosteroids for the Relief of Pain Sensitivity of Dentine and 
Pulp, Oral Surg., Oral Med. and Oral Path., 13: 594-597, May 
1960. 

7. Mosteller, J. H. Use of Prednisolone in the Elimination of Post- 
operative Thermal Sensitivity, A Clinical Study, J. Pros. Dent., 
12: 1176-1179, Nov-Dec 1962. 

8. Mosteller, J. H. The Ability of a Prednisolone Solution to Elimi- 
nate Pulpal Inflammation, J. Pros. Dent., 13: 754-760, July-Aug 
1963. 

9. Vigg, J. Hydrocortisone in Pulp Therapy, Preliminary Results of 
a Clinical Test, D. Prog., 2: 285-287, July 1962. 

10. Ehrmann, E. H. Corticosteriods in Operative Dentistry: A Pre- 
liminary Survey, Aust. D. J., 9: 264-272, Aug 1964. 

11. Fiore-Donno, G. and Baume, L.-J. Effects of Capping Compounds 
Containing Corticosteriods on the Human Dental Pulp, A Long 
Term Histologic Study, Helv. Odont. Acta, 6: 23-32, Oct 1962. 

12. Fiore-Donno, G. and Baume, L.-J. Controles histopathologiques 
du coiffage pulpaire aux corticosteroides, Schweiz. Mschr. Zahn- 
heilk. 73: 413-423, May 1963. 

13. Dachi, S. F., Ross, A. and Stigers, R. W. Effects of Prednisolone 
on the Thermal Sensitivity and Pulpal Reactions of Amalgam- 
Restored Teeth, J. Am. D. Ass., 69: 565-571, Nov 1964. 

14. Sinkford, J. C. and Harris, S. C. The Case Against Topical Use 
of Adrenocorticosteriods in Dentistry, J. Am. D, Ass., 68: 765-767, 
May 1964. 

15. Fry, A. E. Lecture, Am. D. Ass. Meeting, San Francisco, Calif., 
Nov 1964. 

EDITOR'S COMMENT— -The use of corticos- 
teroids in dental procedures is a highly controversial 



16 



U.S. NAVY MEDICAL NEWS LETTER 



issue. Doctor Cotton's excellent review of the litera- 
ture is commended to careful study by all dental 
officers. Until more conclusive long-term histological 
evaluation of pulpal repair after corticosteroid treat- 
ment has been published, the dentist who practices 
conservative management of the pulp will refrain 



from using corticosteroids in treatment of pulpitis 
and pulpcapping cases. He might use corticosteroids 
as an adjunct, but he will not use any of them as a 
substitute for appropriate calcium hydroxide, zinc 
oxide-eugenol, cavity sealer or cement base treat- 
ment. 



PERSONNEL AND PROFESSIONAL NOTES 



U.S. Navy Dental Officer Presentations. CAPT 
Perry C. Alexander DC USN, U.S. Naval Dental 
Clinic, Long Beach, California, served as guest lec- 
turer before the Armed Forces Desert Dental Society 
at a meeting held 22 January 1965 aboard Norton 
Air Force Base, San Bernardino, California. Cap- 
tain Alexander's topic concerned, "Movement of the 
Condyle." 

CAPT Gordon H. Rovelstad DC USN, U.S. Naval 



Dental School, National Naval Medical Center, 
Bethesda, Maryland, presented a lecture entitled, 
"Dental Hygienist in Pedodontics" before the Dis- 
trict of Columbia Dental Hygienists Association on 
15 March 1965 in Washington, D.C. 

CAPT Rovelstad also gave a talk on, "Current 
Concepts of Preventive Dentistry" before the Wash- 
ington County Dental Society on 16 March 1965 in 
Hagerstown, Maryland. 



NAVY DENTISTS PARTICIPATE IN CENTENNIAL MIDWINTER MEETING 



The Chicago Dental Society held its 1 00th Mid- 
winter Meeting in Chicago, February 21-24, 1965. 
The following clinicians and their presentations re- 



presented the United States Navy during the four-day 
convention: 



HALF-DAY SYMPOSIA 



CAPT Theodore R. Hunley DC USN 
NDS Bethesda, Maryland 



A Symposium of Modern Operative 
Procedures 



ESSAY PROGRAM 



CAPT Theodore R. Hunley DC USN 
NDS Bethesda, Maryland 

CAPT Fred L. Losee DC USN 
USNTC Great Lakes, 111. 



Operative Dentistry Supports the 
Treatment of Advanced Periodontal Disease 

Caries, Cancer, and Coronary Disease — 
Is There a Relationship? 



TABLE CLINICS 



CAPT William E. Ludwick DC USN 
USNTC Great Lakes, 111. 

LCDR J. P. Quinn MSC USN 
USNTC Great Lakes, 111. 

LT Alan L. Coykendall DC USN 
USNTC Great Lakes, 111. 

LT Thomas F. Hafner DC USNR and 
LT David R. Sheppard DC USNR 
USNTC Great Lakes, 111. 



Wearing Rubber Gloves in 
Operative Dentistry 

Microbial Aerosol Sampling in 
Dental Clinics 

The Effectiveness of 
Rinsing the Mouth 

Preventing Amalgam 
Failures 



U.S. NAVY MEDICAL NEWS LETTER 



17 



TABLE CLINICS (Cont.) 



LT Robert G. Bachard DC USNR and 
LT Joel Grand DC USNR 
USNTC Great Lakes, 111. 

LT Sheldon B. Bernick DC USNR and 
LT F. D. Carlson DC USNR 
USNTC Great Lakes, III. 

LT Spiral Chaconas DC USNR and 
LT Kosmas Protopappas DC USNR 

USNTC Great Lakes, 111. 



Pathosis of the 
Tongue 



A Method of 
Endodontics 



Indirect Inlays and Bridges 
Using Checkbite Tray 



B, L. Lamberts, Ph.D. and 
T. S. Meyer, M.S. 
USNTC Great Lakes, 111. 



Separations of Salivary 
Proteins 



Irving L. Shklair, Ph.D. 
USNTC Great Lakes, 111. 



C-Re active Protein and Periodontal 
Disease 



NAVAL RESERVE DENTAL COMPANY 9-6 



CAPT Evert A. Archer DC USNR 
Commanding Officer, Chicago, III. 

CAPT Robert J. DeWolf DC USNR 
Evanston, 111. 

CAPT William H. DeWolf DC USNR 
Woodstock, 111. 

CDR Robert B. Jans DC USNR 
Evanston, III. 

LCDR Richard N. Lamermayer DC USNR 
Kenilworth. 111. 



Correction of Premature Contacts 

in the Natural Dentition 

Template Construction 
for Parallel Dowels 

Manipulation of Amalgam-Dry 
Mix Aspect 

Simplified Technics for Extra-Oral 
Mandibular Roentgenograms 

The Class V Gold Foil 
Restoration 



NAVY CIVILIAN RESEARCHER HONORED 



Doctor Irving L. Shklair, a Bacteriologist associated 
with the Dental Research Facility, USNTC, Great 
Lakes, Illinois since 1952, was recently elected 



President of the Chicago Section of the International 
Association for Dental Research. 



NAVY DENTIST RECEIVES AIR FORCE AWARD 



CAPT Louis S. Hansen, DC USN, Head of the 
Officer Education Department, U.S. Naval Dental 
School, Bethesda, Maryland, has been authorized to 
wear the Air Force Outstanding Unit Award ribbon 
permanently. The award was granted to the Armed 
Forces Institute of Pathology "for exceptionally 



meritorious service in support of military operations 
from 1 July 1962 to 30 June 1964," by order of 
the Secretary of the Air Force. During that period, 
CAPT Hansen served as Chief of the Dental and 
Oral Pathology Division of the Institute. 



18 



U.S. NAVY MEDICAL NEWS LETTER 



LIST OF NEWLY STANDARDIZED ITEMS AVAILABLE FOR ISSUE 



FSN 

6520-059-9007 
6520-059-9008 
6520-059-9009 
6520-059-9010 
6520-059-9011 
6520-059-9012 
6520-059-9013 
6520-059-9014 
6520-059-9015 
6520-059-9016 
6520-074-4-193 
6520-965-0006 

6520-965-0009 



6520-965-0011 
6520-965-0012 
6520-965-0013 



6525-074-4542 
6532-890-1429 
7290-890-1822 



NOMENCLATURE 

Band, Copper, Dental Size 8, 12s 

Band, Copper, Dental Size 9, 12s 

Band, Copper, Dental Size 10, 12s 

Band, Copper, Dental Size 11, 12s 

Band, Copper, Dental Size 12, 12s 

Band, Copper, Dental Size 14, 12s 

Band, Copper, Dental Size 17, 12s 

Band, Copper, Dental Size 18, 12s 

Band, Copper, Dental Size 19, 12s 

Band, Copper, Dental Size 20, 12s 

Pulp Protector, Dental, Zinc Oxide and Eugenol 

Wheel, Abrasive, Diamond, Friction Grip Angle 

Handpiece, Cylinder, High Speed, 0.040 by 0.167" 

Wheel, Abrasive, Diamond, Friction Grip Angle 

Handpiece, Inverted Cone, High Speed, 0.045" 

Diameter 

Wheel, Abrasive, Diamond, Friction Grip Angle 

Handpiece, Double Cone, High Speed, 0.120" 

Diameter 

Wheel, Abrasive, Diamond, Friction Grip Angle 

Handpiece, Tapered Cylinder, High Speed, 0.050 

by 0.227" 

Wheel, Abrasive, Diamond, Friction Grip Angle 

Handpiece, Tapered Cylinder, High Speed, 0.055 

by 0.383" 

Hanger, X-ray Film, Processing, Dental 

Apron, Dental, Plastic 

Cover, Headrest, Plastic, Disposable, 500s 



UNIT OF 




ISSUE 


PRIC 


BX 


.25 


BX 


.25 


BX 


.25 


BX 


.25 


BX 


.25 


BX 


.25 


BX 


.25 


BX 


.25 


BX 


.25 


BX 


.25 


PG 


2.30 


EA 


.62 



EA 



EA 



EA 



EA 



.60 



.66 



.63 



.66 



EA 


5.10 


EA 


1.20 


RL 


2.20 



RESERVE DENTIST NAMED TO POST AT PITTSBURGH SCHOOL 



CAPT W. A. George DC USNR, Commanding 
Officer of Naval Reserve Dental Company 4-10, 
has been named assistant dean of the University of 
Pittsburgh School of Dentistry. 

Dr. George is a 1932 graduate of the school, and 
has been on the faculty since 1958, when he became 
professor of dentistry and chairman of the depart- 



ment of prosthetics. He will continue to chair the 
prosthetics department and serve as associate director 
of the graduate program in the school. 

He is a member of the American Dental Associa- 
tion and its Council on Dental Research, and is im- 
mediate past president of the Odontological Society 
of Western Pennsylvania. 



PEOPLE TO PEOPLE INTERNATIONAL RELATIONS 



From time to time, the Dental Division, Bureau of 
Medicine and Surgery learns of dental officers at 
foreign shore stations or in travel status who, on their 
own initiative, practice a commendable level of in- 
ternational relations by becoming acquainted with 
leaders of the dental profession in other nations. In 
some cases, dental officers have visited renowned 
leaders of their specialty fields in other nations. Those 



officers who expect to visit Europe might make de- 
sirable contacts by writing to Doctor Gerald H. 
Leatherman, Secretary-General, International Dental 
Federation, 35 Devonshire Place, London W.l, Eng- 
land. U.K. In similar manner, others might corre- 
spond with Doctor B. B. Erana, Secretary, Asian- 
Pacific Dental Federation, Manila Doctor's Hospital, 
Isaac Peral Street, Manila, R.P. 



U.S. NAVY MEDICAL NEWS LETTER 



19 



OCCUPATIONAL MEDICINE 



THE FUTURE OF HEALTH IN INDUSTRY 

LCDR Carlos Villafana, MC VSN, Indian Head, Md., Industrial Medicine and 
Surgery, 33(12): 861-865, Dec 1964. 



Introduction 

The success of industrial health programs is a 
well-established fact. This accomplishment is the 
end result of the continued enthusiasm, vigor, and 
capability of the industrial physicians who have been 
providing the best of care and health maintenance 
for the workers in their respective industries. They 
have faced innumerable problems and gradually 
changed the scope of occupational medicine from 
the mere treatment of industrial accidents to the 
current practice of an all-inclusive preventive medi- 
cine program in each major industry. The continued 
scientific progress and advances in modern technol- 
ogy are opening new avenues for expansion in this 
field with many new challenges to meet. New and 
exotic chemicals entering the market by the hundreds 
offer a formidable challenge for research on their 
toxicological aspects and their effective control. Radi- 
ation hazards place upon the health team the task 
of finding adequate ways of protection which must 
be based on more knowledge of the complexity of 
this hazard and how to apply this knowledge ration- 
ally. The ever-expanding small industries for which 
so little has been done in the way of providing ade- 
quate occupational health services offer perhaps the 
major area in which occupational medicine should 
move if it is going to live up to its high ideals of 
providing health maintenance and care to all workers 
of all occupations. This is a fertile field for imagina- 
tive industrial physicians. The solution of this prob- 
lem may come from nonmedical factions if the 
industrial physician does not provide the necessary 
leadership. As automation, which in effect is a sec- 
ond industrial revolution, expands more and more, 
it will probably complicate the mental health prob- 
lem in industry, forcing occupational medicine to 
enter the area of mental health in full fashion and 
probably turning this specialty into more of a social 
than a medical science. Herein lies perhaps the 



greatest challenge to physicians in industry. But the 
future of health in industry, complex as it looks, 
glorious as it may be, can be turned into hopeless 
failure if the occupational health team does not pre- 
pare effectively to tackle the present problems, so 
that it can meet the challenges of the future. The 
industrial physician, as the leading member of the 
occupational health team has the greatest share in 
this enterprise. Therefore, this paper will deal pri- 
marily with our role as industrial physicians in assur- 
ing that the future of health in industry is as glorious 
and satisfying as it has been until now. 

In preparing to cope with the challenges ahead, 
we must take inventory of our major problems in 
occupational medicine and what possible solutions 
are available, bearing in mind that these solutions 
must be far-reaching and comprehensive for the 
benefit not only of all workers in industry but for all 
the members of our community. 

EDUCATION IN OCCUPATIONAL MEDICINE 

Recruitment: Our specialty suffers from a formid- 
able shortage of adequately trained personnel. A 
large part of the occupational health services in this 
country are provided by private physicians with slight 
understanding and almost no training in the prin- 
ciples of industrial medicine. This is a big problem. 
Interest in this speciality has been developed in the 
past few years but not sufficiently to motivate many 
individuals to choose it as a career. Our aims should 
be directed not only to recruiting at the medical 
school but also the premedical college and high 
school levels. There are plenty of opportunities to 
introduce, discuss and "sell" industrial medicine to 
community groups, especially youngsters. The role 
of the industrial physician in this respect is invaluable 
because of his privileged position in the community. 
He should conduct lectures and discussions in this 



20 



U.S. NAVY MEDICAL NEWS LETTER 



field in the medical society meetings, in school meet- 
ings, with school counselors and teen-age groups. 
Arranging visits to the plant with school authorities 
offers other opportunities for contacts. Emphasizing 
the industrial physician's role of working for the 
health of groups of people as well as individuals will 
bring out in a few the innate desire to serve. Those 
expressing interest should receive special orientation. 
In this connection, school counselors can be of great 
value in detecting those youngsters with these special 
characteristics, those who are not only scientifically 
but also socially inclined. 

Medical School Training: Lack of exposure to 
occupational medicine as a specialty in medical 
school is one of the greatest reasons for minimal 
enrollment. Inclusion of more hours of occupational 
medicine subjects in the modern medical school cur- 
riculum is a difficult task. Efforts should be made to 
present orientation lectures to all medical students 
on the history, development, the present and future 
of occupational medicine as an adventurous career 
rather than explaining occupational diseases that they 
will probably not see in the future. A pitch for oc- 
cupational medicine should be made by a highly 
successful industrial physician who resides in "the 
area of the medical school and who can deliver a 
speech with inspiration. In the meantime the con- 
stant struggle with medical school authorities to in- 
clude more hours in their programs should be con- 
tinued as well as using the infiltrative techniques 
already suggested by others. 

Graduate Training: The present program of grad- 
uate training in occupational medicine in most 
schools is adequate to prepare physicians for posi- 
tions as medical directors of large companies. How- 
ever, great emphasis is placed on many occupational 
diseases that are out of the picture and very seldom 
found by the industrial physician in his industry. I 
would eliminate some of the occupational health 
seminars having to do with the "old occupational 
diseases" that we do not see too often and use that 
time to concentrate on the new problems facing the 
industrial physicians. 

The teaching of the core courses in occupational 
medicine, such as statistics, public health, and sani- 
tation should be oriented primarily but not entirely 
toward occupational health problems. The applica- 
tion of statistical principles could be better under- 
stood by using practical occupational health situa- 
tions. A basic course in statistics could be given 
followed by a semester or two in occupational health 
statistics. This, in addition to intensive research 



training, I think, will prepare the graduate industrial 
physician to initiate or actively participate in worth- 
while research projects. 

The occupational medicine resident should have 
the same status as any other resident in the hospital. 
Through infiltrative techniques, residents should take 
time to discuss the occupational health aspects of 
particular cases in the hospital with residents of 
other services. This will create awareness of occu- 
pational medicine on their part. For this purpose, 
I think that the residency training in occupational 
medicine should be administered by the medical 
school and not by the public health school even 
though it is an integral part of preventive medicine. 
In this manner, the occupational medicine resident 
will be more accepted and his assistance more fre- 
quently sought by others. This will also bring him 
closer to the medical students where he can introduce 
them to or orient them better in the field of occu- 
pational medicine. Once he becomes a resident, he 
must remember he is a member of the "occupational 
health selling team" for recruitment purposes. 

In the area of training for research, serious de- 
ficiencies are present in some schools because of 
incomplete training and supervision. First, a course 
is needed to prepare residents in the basic principles 
of research, animal and laboratory techniques and 
methods, especially oriented toward the study of 
occupational health. Only after this should the resi- 
dent undertake an original research project in which 
he should have adequate supervision. This partic- 
ular problem is one of the most important having to 
do with preparing the occupational medicine spe- 
cialist of today for the future. 

At the non-graduate level or post-graduate level, 
it should be the responsibility of the Industrial Medi- 
cal Association, American Academy of Occupa- 
tional Medicine, and other industrial health groups 
to conduct research training courses to open the eyes 
of other physicians to this wonderful field and moti- 
vate them to initiate their contribution. 

As I have emphasized already, training in occu- 
pational medicine should be focused on the present 
and future, not in the solved problems of the past. 
There should be preparation for a new glory in 
accomplishing goals, not just recalling past achieve- 
ments. 

As automation becomes more and more a part of 
our daily lives we must prepare to deal with the par- 
ticular stress on individuals imposed by the necessity 
of working in complete or semi-isolated environments 
while, at the same time, maintaining a high techni- 



U.S. NAVY MEDICAL NEWS LETTER 



21 



cal competence. What future effects this may have 
on the mental health of the individual is unpredict- 
able. 

In this connection, extensive training in mental 
health should be given serious consideration in the 
residency program. This should include community 
and plant mental health since the industrial physi- 
cian of the future will probably function more at the 
community than at the plant level. Industrial and 
public health psychiatrists should provide the training 
in this area. The industrial physician will not only 
have to guide the workers with a mental problem to 
obtain adequate care in the community, but also 
he will have to work closely with the patient's physi- 
cian on the rehabilitation of the mentally ill indi- 
vidual. This will become more and more obvious 
as modern psychiatric treatment and techniques are 
put into practice and more people are treated as out- 
patients while holding a job. The industrial physi- 
cian will assume a tremendous burden and responsi- 
bility to be shared with the psychiatrist in caring for 
these patients. Obviously a problem of this nature 
can and will be faced successfully by the industrial 
physician only if he is adequately trained in mental 
health techniques and the principles of psychiatric 
treatment. He should not be a psychiatrist, but he 
should be able to treat most patients with minor to 
moderate mental health problems in his plant. He 
must develop skill in interviewing and counseling, 
in referring patients to psychiatrists and perhaps most 
important, in participating in the rehabilitation of the 
mentally ill individual on his return to work. 

A major emphasis should be placed in residency 
training programs in the teaching of medical care 
and economics. With more and more demands from 
labor unions for comprehensive health care and the 
multiplicity of plans being offered and to be offered 
in the future, management will need advice and coun- 
sel as to what plan is best for the needs of their 
workers. This particular field is rather intricate and 
a practical knowledge of it will enable the industrial 
physician to assist management and labor. Here he 
can perform a unique function for the benefit of the 
workers' health since as a physician he can better 
advise as to what plans provide the best health serv- 
ices. Not only should he know about plans related 
to industry but also about all community health care 
plans since the medical care of the workers for non- 
occupational conditions will become more and more 
his business. In this regard, he can function in a 
position of leadership through his medical society 
and other health groups by becoming-knowledgeable 



in medical care and economics and steering the 
course of specific health events for the benefit of 
the workers and their community. 

Residency training should also be oriented toward 
finding possible solutions to the small plant problem. 
As a part of the training, six months should be dedi- 
cated to providing services to the small plants in the 
area where the trainee is studying. This can be ar- 
ranged by the jnedical or public health school author- 
ities with the management of these plants. This 
program may have three favorable effects. First, occu- 
pational health services of high quality would be pro- 
vided to these plants. Second, the management of 
these plants would be introduced to industrial health 
and its advantages and may decide to continue pro- 
viding these services on their own after the resident 
leaves. Third, a source of industrial physicans can 
be provided through the residents first and followed 
by the local physicians. For the other physicians 
this can be the subject of a postgraduate training 
course (the small plant industry health program) to 
prepare them adequately to serve the small plants. 
In addition, if sponsored by medical or public health 
schools, this may eliminate the problem of not vio- 
lating medical ethics in trying to offer much-needed 
health services to these plants, since individual phy- 
sicians would not be offering their services. 

Postgraduate Training: The American Academy 
of Occupational Medicine, Industrial Medical Asso- 
ciation, and others are engaged in providing a con- 
tinual program of education for industrial physicians, 
especially those without formal training. More post- 
graduate courses in occupational medicine are 
needed in different centers for industrial physicians. 
The American Academy of Occupational Medicine 
has already started a series of courses which should 
be given at least annually. The first one given in 
May, 1963 at Ohio State University was very suc- 
cessful. Training in these courses should be oriented 
toward present and future occupational health prob- 
lems. Toxicology and Mental Health are submitted 
as two of the subjects presenting the most pressing 
problems at the moment and for the future. A course 
in industrial health services for small plants should 
be included also. 

SMALL INDUSTRY PROBLEM 

The problem of providing adequate occupational 
health services for small industries will become more 
and more acute in the future as our attention may be 
diverted to face other difficult and engaging problems 
of increasing complexity. This segment of the ih- 



22 



U.S. NAVY MEDICAL NEWS LETTER 



dustrial health care has been neglected. There is a 
lot of talk about it in industrial medical journals, 
meetings, societies, and so forth, but very little is 
done about it. Management's lack of information on 
the need for occupational health services and where 
to get them, as well as the cost involved and the lack 
of trained people to accomplish this purpose, has 
complicated the problem tremendously. There is no 
doubt that a large segment of the practice of occupa- 
tional medicine is and probably will be the domain of 
the private physician with little or no training in 
occupational medicine who provides routine emer- 
gency care for the employees of their plants. The 
knowledge of these physicians should be increased to 
enable them to provide the kind of services which are 
essential to a good occupational health program. 

1 believe that it is the role of the industrial phy- 
sician to take the lead and through the occupational 
medicine residency training centers and the other 
occupational health groups and county medical soci- 
eties engage in an active program of providing ade- 
quate services of the nature described. Admittedly 
this is a difficult task, but we have to start some- 
where. These entities, as well as the major teaching 
centers, should provide liaison between the manage- 
ment in the small plants and the industrial physicians 
in offering their services and educating management 
as to the advantages of obtaining these services at a 
moderate cost. This should be done alter a regular 
course in occupational medicine, as applied to small 
plants, is developed. Thus, through the teaching 
hospitals using their residents and through these 
agencies using the other industrial and private phy- 
sicians, a drive can be made to solve the small plant 
problem without violating medical ethics. Already 
in Kentucky the Occupational Health Institute has 
set the example by organizing and operating a multi- 
plant occupational health program for small indus- 
tries, and other occupational health groups should 
follow suit, but it is up to the industrial physician to 
take the lead in his own area. 

The physician participating in this program should 
be well aware of the availability of industrial medical 
consultants in his area so that they can be called 
when a particular situation arises. This consultation 
service is already provided by the Industrial Medical 
Association by answering questions and requests for 
information, in writing, but it would be more effective 
if the local physician could use the occupational 
medicine specialist available in his locality for con- 
sultation. The industrial physician should make him- 



self available to other physicians through his county 
medical society. 

Slowly these physicians practicing part-time in in- 
dustry should be made to realize that they should 
function as part of a team which is essentially non- 
medical and that there is in occupational health a 
different way of doing things than in private practice. 
In this way, as a physician in private practice but 
with industrial connections he will develop respect 
and admiration toward occupational health and its 
members and will provide support in the community 
for industrial health programs. 

REHABILITATION 

Rehabilitation not only of the physically handi- 
capped, but also of those with mental illness and 
chronic diseases will probably assume tremendous 
proportions as our population grows older and as 
modern techniques in the treatment of emotional 
disorders are put into practice. The industrial phy- 
sician's responsibility now is not limited to providing 
adequate care and rehabilitation of occupalionally 
incurred diseases or disability. He is called upon to 
work hand in hand with the private physician, the 
psychiatrist, the rehabilitation experts in the commu- 
nity, and others in returning these individuals to 
work as they probably constitute a significant and 
very useful segment of our population. He should 
participate more actively in the legislative activities 
on workmen's compensation to insure that adequate 
coverage consistent with adequate rehabilitation is 
offered. This he can do by attending hearings on 
workmen's compensation in his state and proposing 
from the health standpoint what he feels should con- 
stitute a functioning, practical, adequate program. 
He must educate the other physicians in this area of 
rehabilitation by stressing the need for early referral 
to the specialist after an injury. In doing this, he will 
be performing one of his most important functions as 
an industrial physician. His interest here is derived 
not only as a physician but as a responsible citizen 
of the community who has great power to decide 
whether a man may be a happy useful citizen or a 
burden to society. In this area of rehabilitation lies 
one of the greatest challenges to the nation in the 
future and industrial medicine has a large share of it. 

ENVIRONMENTAL HEALTH 

Preparing for the challenges ahead is going to 
require an active role on the part of the occupational 
health team, and the industrial physician as its 



U.S. NAVY MEDICAL NEWS LETTER 



23 



leading member. This will entail an all-out move- 
ment into the community to -carry out the preventive 
health program which has been so successful in the 
large plants. His role is a big one since he will no 
longer be isolated in the plant; the new problems 
will require community action. Many of these prob- 
lems will be community problems which may have 
originated in the plant or vice versa. The health pro- 
tection of the workers will no longer be his only 
concern. Instead, the demands of the increasingly 
complex environment will require him to work hand 
in hand with other members of the health profession, 
voluntary agencies and government in a joint effort. 
This is perhaps the greatest mandate of occupational 
health today. For success, the industrial physician's 
role will be determined by his preparation for it. 
We have previously emphasized his responsibility in 
obtaining adequate continued training, his role in 
the small plant problem, in rehabilitation, in work- 
men's compensation, in the medical societies, in re- 
cruiting interested young people in the field, in train- 
ing other physicians and groups, in becoming a health 
economist, to function adequately in research and in 
mental health. All these are essential duties of the 
present and future industrial physician if he is going 
to maintain his leadership as a member of the future 
environmental health team. It will appear that he is 
drifting away from the medical profession to enter 
into the social sciences. But this is not really so. As 
a medical member, he will maintain the medical 
skills necessary to occupy such a position, but he 
will not be limited to the specific role of physician 
but rather to a more far-reaching, all-encompassing 
domain, the domain of the individual in relation to 
his environment as a whole. 

RESEARCH 

Health in industry and the community cannot sur- 
vive without adequate research. The challenges 
facing us especially from the toxicological, radiation, 
chronic disease, and mental health standpoints are 
tremendous. This demands that every industrial phy- 
sician participate in some kind of research project at 
all times. Training for this is required for those 
without experience and this has been included in 
residency programs. It should also be included in 
postgraduate training courses for other physicians. 
There is need for more knowledge in those exciting 
fields and also in applying the knowledge we already 
have. Here government's role should be emphasized 
and it should probably be expanded. More research 
projects directly connected with industry should be 



carried out. These should not be limited to large 
medical centers. The industrial physician should re- 
ceive assistance from Public Health Services or from 
such an agency at a state level on how to conduct 
research in a particular problem. This will slowly 
create the necessary climate and desire to investigate 
while meeting all the necessary requirements of good 
research. This help should also be forthcoming at the 
local level from local health departments. 

CONCLUSION 

The future is Jldkd with chalfengcs of immense 
proportions. These are not only of the national level, 
but also intamatiranaL There arc many countries 
undergoing rapid industrialization without adequate 
industrial medicine programs to keep pace with it. 
The ill effects this will have on the physical and 
mental health of the community may be staggering, 
but stands as a mandate for us to participate actively 
in world health. We must increase our channels of 
communication with other countries in this field so 
we can relay our knowledge and they can apply what 
may be suited to their special needs and conditions. 
The industrial physician has his hands full and 
there is much to be done in industrial health. The 
great accomplishment of providing high quality occu- 
pational health programs in large industries should 
be a source of satisfaction but now we should turn to 
the many other unsolved problems and prepare to 
cope with oncoming ones. As we move into the era 
of automation, the laser, the new exotic chemicals, 
the complex radiation hazards, and others, health in 
industry will expand its roots into the community and 
indeed into the whole environment. It will not be 
long before occupational medicine will become en- 
vironmental medicine as the industrial physician 
moves out of the plant "shell" to protect the health 
of the workers in the community too, while perform- 
ing services altogether different from the services 
performed by the other members of the medical pro- 
fession. In this endeavor, as the most important 
member of the environmental health team he will be 
assisted by the environmental hygienist, the environ- 
mental nurse, environmental safety engineer, and 
other members of the present occupational health 
team who will also have to expand their services to 
the environment as it becomes more complex. The 
role of the industrial physician will be one of great 
leadership and the extent to which he is successful 
will depend on his preparation now to face the chal- 
lenges later. 



24 



U.S. NAVY MEDICAL NEWS LETTER 



DISEASES OF WHITE COLLAR WORKERS 

David H. Goldstein, MD and Leo Orris, MD, New York, N.Y., Public Health 
Reports 79(11) Nov 1964. 



Approximately 3 percent of al! occupational^ 
caused disabilities arc attributable to disease. The 
remainder fall into the category of accidental injuries. 
About half of all reported occupational diseases were 
found in blue collar workers or workers engaged in 
manufacturing. Why then this interest in the occu- 
pational diseases of white collar workers? The rea- 
sons arc simple: Occupational diseases arc largely 
preventable, and when they occur they arc expensive. 

The legal definition of an occupational disease 
varies. For the purposes of this study, an occupa- 
tional disease is defined as a compensable disease that 
arises out of and in the course of employment. It is 
any abnormal condition of health due to specific 
occupational hazard other than trauma. In general, 
occupational diseases fit into the following cate- 
gories: dermatoses; diseases due to infectious agents; 
diseases due to dusts, fumes, gases, vapors, or mists; 
or diseases due to physical agents. Newly added are 
aggravation of pre-existing nonoccupational diseases 
and emotional stress. Many times it is exceedingly 
difficult to determine whether a specific illness oc- 
curred on the job or elsewhere, as, for example, in 
the household kitchen. This applies particularly to 
dcrmatological conditions. 

Automation and other technological advances can 
be expected to expand the white collar segment of 
the labor force at the expense of the blue collar 
group. According to the 1960 census, women consti- 
tuted approximately one-third of the total civilian 
working population of the United States. Nationally, 
54 percent of the employed women were in white 
collar jobs. 

A brief outline of present problems may help to 
forecast the problems of the future. 

Dermatoses 

It has been variously estimated that 50 to 80 per- 
cent of all occupational diseases arc diseases of the 
skin. 

Much like all occupational skin diseases, most of 
those alTccting white collar workers arc caused by 
chemical agents, with mechanical, physical, biologi- 
cal, and plant agents playing a lesser role. Chemicals, 
such as the dichrornatcs, resins, plastics, and dyes, 
arc among the most frequent offenders, and they may 
act cither as primary irritants or sensitizers. The 



irritants will cause an eruption at the site of contact 
in any individual, whereas the sensitizers will not 
produce a reaction on initial contact but will sensitize 
the skin so that eruption occurs on later exposure. 
For example, a clerk washing a duplicating machine 
with an alcoholic solution may develop red, dry, 
crusted hands from the irritant action of the solution 
and eventually become sensitized to the ink and react 
violently not only on the hands but on other sites. 
On the whole, white collar workers are more likely 
to develop allergic reactions than industrial workers, 
who arc more exposed to acids, alkalies, and solvents, 
many of which arc strong skin irritants. 

A mail clerk, then, using adhesives and glues may 
be sensitized to the synthetic resins incorporated in 
such material. And the dyes in carbon paper and 
chalk may affect not only the typist and the teacher 
but also the executive giving a "Chalk talk." The 
chemical 4-t butyl catechol was used initially in some 
copy paper processes, and the clerk running the copy 
machine, the secretary collating the papers, and the 
executive reviewing the reports all developed derma- 
titis. When this chemical was identified as the aller- 
gen and eliminated, the dermatitis subsided. How- 
ever, with the proliferation of newer processes, 
trouble from this source may again be encountered. 

The chromatcs arc a frequent cause of dermatitis. 
These chemicals, found in a wide range of materials 
and industries such as ink, textiles, dyes, matches, 
photography, photoengraving, rubber, and cement, 
cause various forms of dermatitis ranging from pri- 
mary irritation to ulceration. The most frequent re- 
action encountered in the occupational group is 
allergic dermatitis caused by the hexavalent salts, 
sodium or potassium dichromatc. The railroad in- 
dustry found that sensitization to dichromates may 
take a long time to develop and even longer to sub- 
side. When dichromates were added to the coolant 
system of dicscl engines as an anticorrosive, it took 
months or years for dermatitis to develop. The first 
cases occurred among those actually engaged in 
filling and draining the radiators. Later other round- 
house workers and then office employees were af- 
fected. Minute amounts of dichromatc became widely 
disseminated and were enough to sensitize many in 
the vicinity. Once acquired, the dermatitis may 
linger, despite removal of the apparent source, be- 



U.S. NAVY MEDICAL NEWS LETTER 



25 



I 



cause of the widespread use of dichromate com- 
pounds and the new sources of exposure that are 
continually being uncovered. For example, it re- 
cently has been found that the pockets of those 
carrying safety matches may contain significant 
amounts of dichromate deposited from the matches. 
Other frequent sources of allergic dermatitis 
among office workers are rubber products. These 
compounds contain two main sensitizing agents, ac- 
celerators and antioxidants, and the puzzling erup- 
tion on a file clerk's hand may be from sensitization 
to a rubber finger cot or rubber bands wrapped 
around the hand. Sometimes a glove-like eruption 
on the hands may be caused by rubber gloves worn 
only while using a duplicating machine. In such 
instances a change to plastic gloves will aid in clear- 
ing the eruption. 

The epoxy resins and plastics which have affected 
many industrial workers also have produced allergic 
skin reactions among white collar workers. These 
compounds are made from monomers which harden 
into the inert polymer. However, sometimes some of 
the monomer does not react completely or is leached 
out during use of the plastic, and allergic reactions 
are induced. Such eruptions have occurred on dental 
technicians working with plastic dentures, on nursing 
assistants preparing acrylic fillings, and on typists 
using plastic earphones when transcribing dictation. 

With the introduction of new fabrics processed for 
crease resistance, sales personnel handling such ma- 
terials have developed eruptions traced to free for- 
maldehyde, unreacted or leached from the formalde- 
hyde-resin finish used in the antiwrinkle process. 
Similar situations have occurred with anti-mildew, 
waterproofing, or other agents. 

The constant introduction of new chemicals and 
processes brings new problems and emphasizes the 
need for continued awareness. 

As already stated, some substances may not only 
irritate but may also sensitize the skin. For example, 
most soaps are strongly alkaline and if left on the 
skin and covered will irritate it. Soaps also contain 
perfumes and occasionally dyes from which allergic 
sensitization can develop and become widespread. 
A file clerk with an eruption on her hands may have 
forgotten the pre-existing irritation under her ring 
and attribute her sudden widespread rash to the glue 
she used for paste-ups. Removing from the ring the 
accumulated soap acquired in dishwashing at home 
will remove both the irritant and the sensitizer. 

Thus a frequent problem is differentiating an erup- 
tion acquired at work from one developing at home 

26 



from cosmetics, detergents, photodevelopers, or 
other agents. In attempting to clarify this problem, 
patch testing in which the suspect material, in proper 
concentration, is applied to the skin for 24 to 48 
hours may be of diagnostic value, A positive reac- 
tion is good presumptive evidence that the material is 
the cause of the eruption. Obviously, a good history 
and differential diagnosis are essential and may re- 
quire the services of a dermatologist, particularly in 
detecting a preexisting dermatosis such as psoriasis 
or lichen planus. These common skin conditions are 
frequently aggravated by mechanical stimuli, such as 
friction, trauma, and pressure, which may also pro- 
duce cuts, abrasions, and callosites among office 
clerks, business machine operators, or sales person- 
nel. Such trauma may result in local infections or 
cause the spread of a psoriatic lesion. Knowing the 
nature of these essentially dermatological conditions 
and their localization in other sites not exposed to 
work hazards will help to establish the nonoccupa- 
tional character of the eruption. 

While the incidence of dermatitis among white 
collar workers from physical agents such as ex- 
tremes of temperature, sunlight, electricity, and ra- 
diation is relatively small, there is an increasing num- 
ber of instances of photosensitizing reactions from 
drugs, in particular, tranquilizers, antibiotics, and 
diuretics. The use of these medications by clerical 
personnel in offices equipped with fluorescent light, 
which emit some ultraviolet, may cause eruptions on 
the face, vee of the neck, and back of the hands. 
Others develop a "winter itch" in the summer by 
being constantly in an air-conditioned environment. 
The lowered indoor humidity, increased air move- 
ment, lack of sweating, and the excessive use of hot 
water and soap, all contribute to overdehydration of 
the skin and damage the stratum corneum. The role 
of bacteria, viruses, fungi, and parasites in contri- 
buting to occupational dermatoses, as secondary in- 
vaders, is well known. However, nurses, laboratory 
assistants, and medical technicians are especially 
prone to primary infection. 

Some plants and woods also produce dermatitis. 
The most common, of course, is poison ivy. While 
such contact is not unusual to inhabitants of offices, 
some white collar workers, such as surveyors or re- 
porters, may contact the weed during outdoor duties. 
Other sources of trouble have been woods such as 
cocobolo and the cashew. The cocobolo may be 
used in the handle of a letter opener, and the cashew 
fashioned into Voodoo dolls. Sales personnel and 
buyers have developed eruptions from handling these 
dolls, particularly those who are sensitive to poison 

U.S. NAVY MEDICAL NEWS LETTER 



ivy. The sensitizers in both the cashew and the ivy 
are related catechol compounds. 

Most occupational dermatoses are preventable, 
and the primary object in any preventive program 
is personal and plant cleanliness. Washing with a 
mild soap will effectively remove most irritants or 
sensitizers from the skin. Where the exposures are 
continuous and hazardous, gloves and other clothing 
of a material impervious to the irritant will protect 
the skin. 

In some offices waterless-type cleaners are being 
used increasingly. These agents, usually liquid or a 
semisolid grease, effect cleansing by their solvent, 
alkali, or wetting agent content. The most useful 
and least harmful waterless cleanser is based prin- 
cipally on wetting agents with a neutral pH. The 
value of protective ointments is disputed, but in any 
event they are of limited use among white collar 
workers because of the very nature of their duties. 

Diseases Other Than Dermatoses 
Health workers may acquire specific infections 
from exposures encountered in their daily work. For 
example, pulmonary tuberculosis among hospital 
nurses continues to be reported and is deemed com- 
pensable. In New York State for the year 1959, 
of the 2,896 occupational disease cases closed, 92 
were designated tuberculosis and 149 were classified 
contagious and infectious. The latter category, while 
not specified by diagnosis, ranged from hepatitis to 
amebiasis. The incidence of infectious hepatitis has 
increased markedly in the past few years. This may 
be interpreted as arising in the course of occupation 
when either of the following circumstances prevails: 

(a) a white collar worker develops hepatitis within 
2 to 6 weeks from the time a fellow worker with 
whom he had close contact came down with hepatitis 

(b) an employee travels on company business to an 
area having high incidence of infectious hepatitis 
and develops the disease within the appropriate in- 
cubation period. 

In this era of rapid travel, the practice of sending 
employees abroad on company business has in- 
creased significantly If disease is acquired in the 
course of travel in areas where the hazard of acquir- 
ing such disease is many times greater than at home, 
then such disease has been declared occupational. 
Amebiasis and malaria are examples. 

Food poisoning acquired in on-premises eating 
facilities provided by management has been inter- 
preted as an occupational disease. 

Infrequently, irritative and at times true allergic 
bronchitis are induced by materials handled in rou- 
tine office practice. Both the solvents and the dyes 



incorporated in duplicating and hectograph inks have 
exhibited this potential. 

The incidence of heavy metal or solvent poisoning 
among white collar workers has been low. Most of 
the cases have been encountered among laboratory 
workers who have failed to exercise appropriate pre- 
cautions. 

Radiation-induced skin cancer among physicians 
using x-ray equipment for diagnostic and therapeutic 
purposes is, happily, largely an affair of the past. 
While the safety record of the present atomic energy 
era has been remarkably good, accidents have oc- 
curred. Total body radiation exposures of serious 
and at times fatal consequence have occurred among 
scientists working with reactors. Most episodes have 
taken place during criticality operations. Cataracts 
have been reported among those working with the 
cyclotron. Microwave radiation encountered in the 
use of highpowered radar is capable of producing 
body injury through its thermal effects as well as 
through its capacity to induce opacities in the cry- 
stalline lens of the eye (cataract formation). Such 
effects have been produced experimentally in animals 
and by accident in both white collar and blue collar 
workers. 

Industrial applications of radiation-producing 
equipment are found in metal radiography, gauging 
and control equipment, devices for the suppression 
of static electricity, and in the study of mechanical 
and chemical reactions with tracer isotopes. 

The use of laser devices is currently a burgeoning 
technology. The highly parallel, intense beams of 
light produced have introduced new hazards to the 
occupational environment. The thermal effects on 
the skin and the eye, especially the retina, are well 
known. Less well understood are the athermal effects 
produced by the electromagnetic fields these devices 
create. 

Travel by airplane has at times given rise to aero- 
otitis, an acute disease of the ear resulting from pres- 
sure differences in the middle and external ear. The 
eardrum may become hemorrhagic and perforate. 

The introduction of hyperbaric oxygen therapy 
under two or three atmospheres of pressure provides 
a real hazard of compression sickness for hospital 
staff and attendants. 

Until recent times, occupational loss of hearing 
has been confined to blue collar workers engaged in 
heavy and noisy manufacturing. 

The introduction of automated equipment for a 
variety of clerical operations has presented a new 
hazard to the noise-sensitive white collar worker. 
While the computer itself may be quiet, sorters and 



U.S. NAVY MEDICAL NEWS LETTER 



27 









printers used in automated operations may produce 
noise in the intensity range of 85 decibels. As with 
most occupational disease hazards, this one is also 
preventable. Changes in design of the machine and 
sound-proofing room materials are the answer. 

Several States in the past few years have awarded 
compensation to workers who have developed acute 
psychoneurotic or psychotic reactions to unusually 
stressful business, interperso^l relationships, or 
work situations. 

There is a growing trend in some States to concede 
as occupational and compensable the aggravation of 
pre-existing medical disease as a result of some oc- 
cupational stress. Notable examples are arterioscle- 
rotic heart disease where myocardial infarction su- 
pervenes while at work, and dermatitis aggravated by 
the use of soaps or physical abrasion on the job. 

Summary 

In general, the incidence of occupational disease 
is low among all workers, and lower in white collar 



I 



workers than blue collar workers. Dermatitis con- 
tinues to be the leading cause of occupational dis- 
ease among both white collar and blue collar work- 
ers. 

In this era of automation, advances in chemistry, 
and expanded application of atomic energy, new 
hazards are being introduced to the labor force. The 
impact of these technological advances is evident 
among the expanding population of white collar 
workers who are now manifesting occupational ill- 
nesses not previously seen in this group. Most of 
these afflictions are identical to those of production 
workers, but they are more readily preventable. An 
awareness by occupational health workers of the 
toxicological potential of new devices and chemicals, 
as well as vigilance in the recognition of long-estab- 
lished hazards, is fundamental to their control. Much 
more difficult in diagnosing occupational diseases 
among white collar workers is the distinction be- 
tween illnesses acquired on the job and off the job. 



DEPARTMENT OF THE NAVY 

U. S. NAVAL MEDICAL SCHOOL 

NATIONAL NAVAL MEDICAL CENTER 

BETHESDA. MARYLAND 20014 



POSTAGE AND FEES PAID 
NAVY DEPARTMENT 



OFF1CAL BUSINESS 



PERMIT NO. 1048 



IRY SIUL-2 

Vtiz surgeon <;e^eral, da, 



V i I C £ 
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WASHINGTON 25, D.C. L-3-61 



U.S. NAVY MEDICAL NEWS LETTER